Chapter 1 Neck
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NECK: GENERAL
HISTORY
The anatomic and surgical history of the general neck, thyroid, parathyroids, trachea, and salivary glands is shown in Table 1-1.
Table 1-1. Anatomic and Surgical History of the Neck, Thyroid, Parathyroids, Trachea, and Salivary Glands
Egypt
2780- Statues show signs of Graves' disease
2280
B.C.
India
2000- The Hindu Rig Veda mentions tracheal cannulation
1000
B.C.
China
1600
B.C.
Used burnt sponge and seaweed to treat goiters
Sushruta
600
B.C.
Introduced the nasolabial flap
India
400
B.C.
The Ayur Veda discusses the treatment and diagnosis of goiters
Egypt
69-30 A temple wall engraving shows Cleopatra with goiter
B.C.
Celsus
50-30 Described the appearance and surgery of cystic goiters
B.C.
Galen (ca. 130200 A.D.)
Considered the thyroid a buffer between the heart and the brain. Called the thyroid cartilage thyreos, meaning "oblong shield."
Paul of Aegina
(625-690)
Surgically treated a bronchocele. Attributed parotitis to humoral imbalance in the head (collecting in the parotid gland during fevers, for
example).
Ali-ibn-Abbas
ca.
990
Reported on the surgical treatment of goiters
Abul Casen
Ebn Abbas
(Albucasis)
1050
Treated "elephantiasis" of the throat (goiter) surgically and stopped hemorrhage using Khalaf cautery and ligatures
Wang Hei
1475
Described the thyroid gland while recommending that dried thyroid be used to treat goiter
da Vinci (14521519)
Provided illustrations of the thyroid glands
Paré (1510-
Described the parotid glands as "emunctories of the brain"
1590)
Vesalius
1543
Wrote of and illustrated the "Glandes laryngis radici adnatae" (thyroid glands) in Fabrica
Eustachius
1563
Described the connection point of the two thyroid lobes as an "isthmus"
Severino
(1580-1656)
Performed a tracheotomy to open an obstructed airway. Constructed a trocar to maintain air passage after the procedure.
Casserio
1601
Described the thyroid glands, calling them "the glands of the larynx"
Fabricius
1620
Thought of a goiter as an enlargement of the thyroid glands
Feyens
1649
Performed a tracheotomy, calling it a "bronchotomy"
Wharton
1656
Used the term "thyroid" correctly in his Adenographia. He believed that it served to lubricate, drain, and warm the larynx.
Hesiter (16831758)
Established the term "tracheotomy," and provided the first description of surgical excision of goiter
Von Haller
1743
First to describe a carotid body tumor
Duphenix
1757
Wrote of gustatory sweating in the Memoirs de L'Academie Royale de Chirurgie
Gooch
1773
Reported two thyroidectomies
Von Haller
1776
Classified the thyroid, thymus, and spleen as glands without ducts that release their fluids into the bloodstream
Parry
1786
Offered an original account of exophthalmic goiter
Desault
1791
Reported a successful excision of part of the thyroid
Blizzard
1811
Successfully ligated the superior thyroid arteries, offering another form of thyroidectomy
Coindet
1820
Recommended iodine as a treatment for goiter
Parry
1825
In a posthumously published paper (d. 1822), he first described the effects of "thyrotoxicosis" — now known as Graves' disease (in England)
and Basedow's disease (in Europe)
Graves
1835
Observed and described effects of an overactive thyroid
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Owen
1852
Described the parathyroid gland of a rhinoceros
Buck
1853
Performed a partial laryngectomy
Lushka
1862
Described carotid body tumors in great detail
Czerny
1870
Performed laryngectomies on 5 dogs (4 died)
Gull
1873
Described primary myxedema
Billroth
1873
As reported by Gussenbauer in 1874, he performed a laryngectomy
P. Von Bruns
1878
Argued, "The attempt at radical extirpation of cancer of the larynx by means of thyrotomy has proved itself completely unsatisfactory and
worthless."
Reigner
1880
Attempted excision of a carotid body tumor
Sandström
1880
Described the parathyroid glands, suggesting they were embryonic portions of the thyroid
Rehn
1880
Performed a thyroidectomy to treat exophthalmic goiter
Steida
1881
Described thyroid development
Billroth
1881
Reported 48 thyroidectomies performed since 1877, in which only four patients died. First to use artery forceps to prevent and stop
hemorrhage. Noted the presence of post-surgical tetany in many of his patients.
Kocher
1883
Reported his first 100 thyroidectomies (30 of which were total thyroidectomies). Method involved ligating the thyroid arteries outside the
capsule and the gland with an aneurysm needle, and ligating as close to the carotid artery as possible. Used a transverse collar incision now
bearing his name. Noted the presence of "cachexia stermipriva" or postoperative myxedema in his total thyroidectomy patients.
Born
1885
First used term "lateral thyroid"
Von MikuliczRadecki
1886
Described and performed subtotal thyroidectomy to avoid complications arising from removal of the gland
Maydl
1886
Successfully removed a carotid body tumor. The patient suffered a postoperative stroke, causing hemiplegia and aphasia, and later died.
Horsley
1886
Observed nervous system depression after thyroidectomy in monkeys. Concluded that the thyroid secreted a vital substance.
M. Mackenzie
1887
Opposed total laryngectomy in the case of Emperor Frederick II of Prussia
Von MikuliczRadecki
1888
Reported a case in which the patient experienced sweating involving submandibular (submaxillary) and parotid gland swelling (later named
Mikulicz' disease)
Albert
1889
Successfully removed a carotid body tumor without postoperative stroke
Von
Recklinhausen
1891
Observed and described osteitis fibrosa cystica in hyperparathyroidism
Gley
1891
Described tetany following removal of the parathyroid glands during thyroidectomy
Kocher
1895
Reported 900 cases of thyroidectomy with a mortality rate slightly higher than 1%. Avoided total thyroidectomies whenever possible.
1898
Reported an additional 600 thyroidectomies with only 1 operative death (caused by anesthesia).
Vassale and
Generali
1896
Introduced the term "parathyroid"
Butlin
1900
Advocated clearing out the anterior triangle of the neck (especially its lymphatic component) to combat the spread of metastatic disease from
the tongue
Loeb
1901
Observed occurrence of tetany in frog muscle deprived of calcium
M. Askanazy
1903
Hypothesized on the relation between parathyroid tumors and osteitis fibrosa cystica
C. Mayo
1904
Presented a paper on thyroid surgery to the American Surgical Association. Reported 40 cases of Graves' disease that were treated by
thyroidectomy.
Erdheim
1906
Studied the relationship between parathyroid glands and calcium metabolism, noting compensatory hypertrophy and osteomalacia
Halsted
1906
Provided dietary supplements of parathyroid glands from cattle to confront clinical tetany. Experimented with transplantation of the
parathyroids.
Crile
1906
Reported on 132 cases in which he performed a radical neck excision. Procedure included en-bloc resection of the regional lymph nodes,
sternocleidomastoid muscle, internal jugular vein, and submandibular (submaxillary) salivary gland.
C. Mayo
1907
First to use the term "hyperthyroidism"
MacCallum and 1908
Voegtlin
Studied hypoparathyroidism and its relation to low serum calcium. Found that injecting calcium relieved tetany.
C. Jackson
1909
Performed the first modern tracheostomy
C. Mayo
1912
Operated on 278 patients with exophthalmic goiter without a death. Recommended the division of the strap muscles for adequate exposure
(visualization of the recurrent laryngeal nerve) and for the preservation of the parathyroids to decrease the risk of tetany.
Kendall
1914
Isolated thyroxine
Schlagenhaufer 1915
Found that a tumor, not compensatory hypertrophy, is present in osteitis fibrosa cystica. Recommended the excision of parathyroid tumors.
Lipsztat
1922
Observed gustatory sweating near the parotid gland
L. Frey
1923
Published article on auriculotemporal nerve syndrome involving the parotid gland. The disease was later named Frey's syndrome.
Hanson
1924
Extracted parathyroid hormone
Mandl
1925
Removed a parathyroid adenoma
Harington
1926
Determined the chemical structure of thyroxine
Collip
1926
Linked hyperparathyroidism to elevated serum calcium (also isolated parathyroid hormone in 1925)
DuBois
1926
Removed a parathyroid adenoma – finally found in the mediastinum after seven previous explorations – in a patient with osteitis fibrosa
cystica due to hyperparathyroidism
Harington and
Barger
1927
Synthesized thyroxine
Weller
1933
Believed that 3 primordia are responsible for thyroid genesis ("lateral thyroid primordium")
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Gilmour
1938
Published his studies on the gross and histological anatomy of the parathyroid glands
Hyde
1944
Reported on the total removal of a cervical thymic cyst
Ramsay
1950
Transplanted and cultured the 4th pharyngeal apparatus; was not able to produce thyroid tissue, but produced parathyroid and thymic tissue
Wendlet
1950
Synthesized cortisol
Martin
1951
Published Neck Dissection, which outlined his experiences with prophylactic neck dissection as a treatment for cervical cancer
Gross and Pitt- 1953
Rivers
Extracted triiodothyronine from the thyroid gland. Later synthesized it as liothyronine.
Redon
1955
Published his classic report on the surgery of the salivary glands
Martin
1957
Published his classic work, Surgery of Head and Neck Tumors
Patey,
Thackray, and
Keeling
1965
Published an extensive report describing the behavior of salivary gland tumors and their treatment
Pearse
1966
Renamed the interfollicular cells the "C" cells because of their calcitonin-producing properties
Toye and
Weinstein
1969
Established the concept of minimally invasive airway access for surgery
Beahrs
1977
Detailed technique and surgical anatomy of radical neck dissection
Conley and
Clairmont
1977
Described the use of the scapula flap for reconstruction
Futrell et al.
1978
Described platysma myocutaneous flap use in neck reconstruction
Ariyan
1979
Described the use of the pectoralis major myocutaneous flap in neck reconstruction
Panje et al.
1987
Described gastroomental flap use in neck reconstruction
Gaz
1987
Noted the unusual location of parathyroid glands in surgical patients
History table compiled by David A. McClusky III and John E. Skandalakis.
References:
Albright F. A page out of the history of hyperparathyroidism. J Clin Endocrinol 1948;8:637-657.
Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63:73-81.
Beahrs OH. The surgical anatomy and technique of parotidectomy. Surg Clin North Am 1977;57:477.
Beahrs OH. Presidential Address: Lest we forget. Surgery 1987;102:893-897.
Becker WF. Presidential Address: Pioneers in thyroid surgery. Ann Surg 1977;185:493-504.
Burton MJ, Brochwicz-Lewinski M. Lucja Frey and the auriculotemporal nerve syndrome. J Roy Soc Med 1991;84:619-620.
Cady B. History of thyroid and parathyroid surgery. In: Cady B, Rossi RL (eds). Surgery of the Thyroid and Parathyroid Glands (3rd ed). Philadelphia: W.B. Saunders,
1991. pp. 1-4.
Colcock BP. Lest we forget: A story of five surgeons. Surgery 1968;64:1162-1171.
Conley JJ, Clairmont AA Jr. Regional flaps in ablative surgery in the head and neck. Am Fam Physician 1977;15:100-105.
Futrell JW, Johns ME, Edgerton MT, Cantrell RW, Fitz-Hugh GS. Platysma myocutaneous flap for intraoral reconstruction. Am J Surg 1978;136:504-507.
Givel JC. Historical review. In: Givel JC (ed). Surgery of the Thymus: Pathology, Associated Disorders and Surgical Technique. Berlin: Springer-Verlag, 1990, pp. 1-8.
Gray SW, Skandalakis JE, Akin JT Jr, Droulias C, Vohman MD. Parathyroid glands. Am Surg 42(9):653-656, 1976.
Ioannides C, Fossion E. Nasolabial flap for the reconstruction of defects of the floor of the mouth. Int J Oral Maxillofac Surg 1991;20:40-43.
Liapis C, Gougoulakis A, Karydakis V, Verikokos C, Doussaitou B, Skandalakis P, Gogas J, Sechas M. Changing trends in management of carotid body tumors. Am Surg
1995;61:989-993.
McIntosh D. Surgical interests in some anomalies of the cervical viscera. J R Coll Surg Edinburgh 1979;24(4):191-204.
Martin H. Surgery of Head and Neck Tumors. New York: Hoeber-Harper, 1957, pp. 3-13.
Martin H, Valle BD, Ehrlich H, Cahan WG. Neck dissection. Cancer 1951;4:441-499.
Nelson WR. In search of the first head and neck surgeon. Am J Surg 1978;154:342-346.
Pahor AL. Historical article: Ear, nose and throat in ancient Egypt. J Laryngol Otol 106:863-873, 1992.
Panje WR, Little AG, Moran WJ, Ferguson MK, Scher N. Immediate free gastro-omental flap reconstruction of the mouth and throat. Ann Otol Rhinol Laryngol
1987;96:15-21.
Ramsay AJ. Experimental studies on the developmental potentialities of the third pharyngeal pouch in the mammalian embryo (mouse). Anat Rec 1950;106-234.
Schwartz SI. Little glands, big names (editorial). Contemp Surg 1993;42:402.
Wilkins EW Jr. Thymoma. In: Pearson FG, Deslauriers J, Hiebert CA, McKneally MF, Ginsberg RJ, Urschel HC (eds). Thoracic Surgery. New York: Churchill Livingstone,
1995, p. 1419.
Wilkins EW Jr. Thymectomy. In: Pearson FG, Deslauriers J, Hiebert CA, McKneally MF, Ginsberg RJ, Urschel HC (eds). Thoracic Surgery. New York: Churchill Livingstone,
1995, p. 1483.
EMBRYOGENESIS OF THE NECK
Normal Development
The neck, as seen in the adult human, does not exist in the embryo. The embryogenesis of the region is that of the organs contained within it: chiefly the
pharynx and its derivatives, the thyroid, parathyroid, and thymus gland (the last is also considered part of the superior mediastinum). In addition, vessels
passing through the neck from the head to the thorax are elongated and modified during the course of development.
The pharynx elongates at 5 weeks and the esophagus elongates later. After the diaphragm has descended, these three structures separate the head of the
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The pharynx elongates at 5 weeks and the esophagus elongates later. After the diaphragm has descended, these three structures separate the head of the
developing embryo from the relatively large heart. By 7 weeks, a neck is visible (Fig. 1-1). Further details of differentiation and migration will be discussed in
the chapters on the specific organs.
Fig. 1-1.
The development of the neck. A, Fifth week. Prominent branchial arches mark the site of the neck. B, Seventh week. Branchial arches are reduced, a constriction
appears between head and thorax. C, Twelfth week. From this stage on, the true neck is present. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical
Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
We present a very brief description of the pharyngeal apparatus to help the student understand clinically applicable accounts of the autogenic origin of the
many anatomic entities of the neck, as well as their phylogenetic significance. The embryonic pharynx consists of a lateral branchial apparatus on each side,
and the unpaired ventral floor between them. Each lateral branchial apparatus is formed by endodermal pouches, ectodermal branchial clefts, mesodermal
branchial arches, and branchial membranes (closing plates).
The unpaired floor is of endodermal origin and produces the tongue, thyroid gland, larynx, and trachea. The embryogenesis of the four arches starts in the
fourth and fifth weeks. They are marked externally by the four ectodermal branchial or pharyngeal clefts on each side. At the same time, the pharyngeal
pouches develop internally. Characteristically, they do not communicate with the clefts.
The bridges between the arches are the branchial membranes, or closing plates, which are formed by the ectoderm and endoderm (Figs. 1-2, 1-3).
Fig. 1-2.
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Drawings illustrating the human branchial apparatus. A, Dorsal view of the cranial part of an early embryo. B to D, Lateral views, showing later development of the
branchial arches. E to G, Facial views, illustrating the relationship of the first arch to the stomodeum or primitive mouth. H, Transverse section through the cranial
region of an embryo, illustrating the branchial arch components and the floor of the primitive pharynx. I, Horizontal section through the cranial region of an embryo,
illustrating the branchial arch components and the floor of the primitive pharynx. Each arch contains a cartilaginous component, a nerve, an artery, and a muscular
component. J, Sagittal section of the upper region of an embryo, illustrating the openings of the pharyngeal pouches in the lateral wall of the primitive pharynx.
(Based on Moore KL. The Developing Human: Clinically Oriented Embryology. Philadelphia: WB Saunders, 1973.)
Fig. 1-3.
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Branchial grooves, branchial arches, pharyngeal pouches, and closing plates. (Modified from Brantigan OC. Clinical Anatomy. New York: McGraw-Hill, 1963; with
permission.)
Remember
All pharyngeal grooves (clefts) disappear except the first one, which remains as the external auditory canal (external auditory meatus).
All the pharyngeal membranes (closing plates) disappear except the first one, which remains as the tympanic membrane (eardrum).
The pharyngeal arches:
– The first (mandibular) pharyngeal arch is responsible for the embryogenesis of the muscles of mastication, the upper and lower jaws, and the cheek and lower
eyelids. Innervation is by the mandibular branch of the trigeminal nerve (V), and its blood supply is from the facial artery.
– The second (hyoid) pharyngeal arch is responsible for the embryogenesis of the muscle of facial expression and for the styloid process, stylohyoid muscle,
stylohyoid ligament, part of the hyoid bone, the stapes and stapedius muscle, and the posterior belly of the digastric muscle. Its nerve is the facial (VII), and its
artery is the external carotid.
– The only muscle thought to be derived from the third (thyrohyoid or glossopharyngeal) pharyngeal arch is the stylopharyngeus. It is innervated by the
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glossopharyngeal nerve. The artery is the common carotid.
– The fourth pharyngeal arch is unnamed. It is responsible for the embryogenesis of the cricothyroid muscle of the larynx. Its nerve is the superior laryngeal branch
of the vagus nerve.
– For all practical purposes, the fifth arch does not exist.
– The sixth arch fuses with the fourth for the formation of the laryngeal cartilages, thyroid cartilage, and perhaps the aortic arch, right subclavian artery, pulmonary
arteries, and ductus arteriosus. Mesoderm of the sixth arch is responsible for the embryogenesis of the pharyngeal constrictors, pharyngeal muscles, and the
laryngeal muscles. Its nerve is the recurrent branch of the vagus nerve.
The pharyngeal pouches:
– The first pharyngeal pouch is responsible for the embryogenesis of the eustachian tube, tympanic cavity, mastoid antrum (about 9th month of gestation), and
mastoid air cells (about 2 years of age). Small benign growths called cholesteatoma 2 in the form of thickenings of the endodermal lining of the middle ear develop
and are said to commonly cause hearing losses. While their origin is not fully understood, it is believed that they form normally in all embryos, but occasionally some
persist and proliferate to form these growths.
– The second pharyngeal pouch produces the palatine tonsils and the tonsillar fossa. Note: A persisting second plate opening can appear as a branchial cleft sinus,
notoriously open into the tonsillar fossa.
– The third pharyngeal pouch: the dorsal part is responsible for the genesis of the lower parathyroids (parathyroids III); the ventral part for the thymus. In the adult
pharynx, the piriform recess is the site of the third pouch.
– The fourth pharyngeal pouch: the dorsal part is responsible for the genesis of the upper parathyroids (parathyroids IV); the ventral part may be involved with a
small amount of thymic tissue and with the ultimobranchial body.
– For all practical purposes, the fifth pharyngeal pouch, like the fifth pharyngeal arch, does not exist.
Congenital Anomalies
Fistulas, external and internal sinuses, and cysts are the result of obliteration of pharyngeal clefts and pouches. Thymic and parathyroid deficiencies (e.g.,
DiGeorge syndrome) are secondary to partial or total agenesis of the parathyroid and thymus glands.
Neck hygromas are congenital malformations of the lymphatic system of the neck. Gidvani and Bhowmick3 indicated that cystic hygromas are common
congenital neck masses, tend to develop in the left posterior triangle, and appear early in life. The authors reported the case of a posterior cervical midline
cystic hygroma.
Remember
Most pharyngeal fistulas and cysts originate from the second pharyngeal pouch and cleft.
Fistulas of the second pouch open at the lower one-third of the medial border of the sternocleidomastoid (SCM) muscle.
Anomalies of the first cleft are related to the facial nerve.
A pharyngeal sinus or fistula typically travels from the pharyngeal wall, between the internal and external carotid arteries, to reach the skin. In 1993, Miller and
Cohn 4 presented the 31st report of a fourth branchial pouch sinus.
SURGICAL ANATOMY
Surface Anatomy
Landmarks
The most prominent landmarks of the surface anatomy of the neck, especially in males, are as follows:
The sternocleidomastoid muscle separates the anterior part of the neck (anterior triangle) from the posterior part of the neck (posterior triangle).
In males with well-developed musculature, the lateral portion of the trapezius muscle produces much of the fullness of the gentle curve that joins the lateral
posterior part of the neck with the shoulder region. The anterior tuberosity of the transverse process of the sixth cervical vertebra (carotid tubercle of Chassaignac) is
located at the medial border of the sternocleidomastoid and at the level of the cricoid cartilage. Pressure at this point will compress the common carotid artery.
In the midline, from above downward, the following landmarks are noted:
– The most prominent midline feature and the most readily palpated is the thyroid cartilage, the "Adam's apple," which is especially prominent in post-pubertal males.
It is located between the third and fifth cervical vertebrae. The bifurcation of the common carotid artery is located on the horizontal plane at this level. Variations in
the site of division of the carotid artery will always be located above this point.
– The body of the hyoid bone can be palpated at about 1.5 cm above the thyroid cartilage at the level of the third cervical vertebra. (Note: At the midpoint of a line
between the mastoid process and the thyroid prominence, the greater horn of the hyoid bone can be palpated laterally.)
– The arch of the cricoid cartilage is palpable just inferior to the thyroid cartilage. The cricoid cartilage forms the only complete cartilaginous ring around the airway,
something that is not observed with the other cartilages of the respiratory system.
– The cricoid cartilage is located at the level of the sixth cervical vertebra.
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– The cricoid cartilage is located at the level of the sixth cervical vertebra.
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A horizontal plane approximately at the junction of the sixth and seventh cervical vertebrae can be associated with the following anatomic entities (Figs. 1-4, 1-5, 16, and 1-7):
– pharyngoesophageal junction
– laryngotracheal junction
– inferior thyroid artery (which is ventral to the middle cervical ganglion), and then (in order), the carotid sheath, and the omohyoid muscle
– entrance of the inferior laryngeal nerve (recurrent nerve) into the larynx
– entrance of the vertebral artery into the transverse foramen of the sixth cervical vertebra and, slightly more inferiorly, the stellate ganglion
– thyroid isthmus and the greatest height of the thoracic duct, which are located at the level of the seventh cervical vertebra
Fig. 1-4.
The third cervical vertebra is at the level of the hyoid bone; the fourth and fifth cervical vertebrae are at the level of the thyroid cartilage. (Modified from Brantigan
OC. Clinical Anatomy. New York: McGraw-Hill, 1963; with permission.)
Fig. 1-5.
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Sixth cervical vertebra. (Modified from Brantigan OC. Clinical Anatomy. New York: McGraw-Hill, 1963; with permission.)
Fig. 1-6.
Seventh cervical vertebra. (Modified from Brantigan OC. Clinical Anatomy. New York: McGraw-Hill, 1963; with permission.)
Fig. 1-7.
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Diagrammatic cross section through the neck below the hyoid bone showing the layers of the deep cervical fascia and the structures that they envelop. (Modified
from Skandalakis JE, Gray SW, Skandalakis LJ. Surgical anatomy of the oesophagus. In: Jamieson GG (ed). Surgery of the Oesophagus. Edinburgh: Churchill
Livingstone, 1988; with permission.)
Surgical Applications
The consistency of cervical skin changes with age. Hyperextension of the neck will give a better appreciation of the topography of the underlying structures in
relation to the skin.
The surgeon selects the proper incision and its placement in relation to the underlying pathology. The orientation of the connective tissues of the dermis
creates lines of tension in the skin, known as the lines of Langer, which are associated with skin creases of the body. Generally speaking, the transverse
incision is cosmetically superior to the vertical, since crossing the normal skin lines will produce a more prominent scar.
However, the vertical lines produce excellent exposure for surgery of the arteries. Most of the commonly used incisions in the neck are presented in Figures
1-8 and 1-9. Combinations of vertical and transverse incisions can be used, if necessary. Remember, a superiorly-based apron flap should be used for neck
dissection. Close the edges of the divided platysma muscle carefully, and reapproximate the margins of the skin incision meticulously to lessen the likelihood
of unsightly scarring from tension upon the skin.
Fig. 1-8.
Proper placement of incisions in the neck paralleling the normal lines and creases of the skin. A, Excision of congenital sinus: partial mobilization here and lower
segment at B1 . B, Excision of carotid tumor or branchial cleft cyst. C, Diverticulum of esophagus. D, Scalenotomy or phrenic nerve interruption. E, Drainage of
submental abscess. F, Excision of thyroglossal cyst or sinus. G, Cricothyreotomy. H, Tracheotomy. I, Thyroidectomy. J, Drainage of cervical abscess at angle of jaw.
K, Exposure of internal or external carotid arteries. L, Exposure of common carotid artery. M, Exposure of brachial plexus or subclavian artery. (Modified from Anson
BJ, McVay CB. Surgical Anatomy (5th ed). Philadelphia, Saunders, 1971; with permission.)
Fig. 1-9.
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Selected incisions used for classic radical neck dissection. A, Attie. B, Eckers and Byer. C, MacFee. D, Morestin. E, Conley. F, Latyshevsky and Freund. G, Martin. H, Z.
I, Barbosa. (Modified from Strong EW. Radical neck dissection. In Nyhus LM, Baker RJ (eds). Mastery of Surgery, 2nd Ed. Boston: Little, Brown, 1992; with
permission.)
Roon and Christensen 5 subdivided the areas of the neck into three regions with respect to injuries:
– High (above the angle of the mandible)
– Middle (between the angle and the bottom of the cricoid cartilage)
– Low (below the cricoid cartilage)
Surgeons continue to use Roon and Christensen's classification, but they now refer to zones (Fig. 1-10): Zone I is the area Roon and Christensen called
"low"; Zone II, middle; Zone III, high.
Fig. 1-10.
Zones of the neck. The junction of zones I and II is variously described as being at the cricoid cartilage or at the top of the clavicles. The important implication of a
zone I injury is the greater potential for intrathoracic great vessel injury. (Modified from Jurkovich GJ. Definitive care phase: neck injuries. In Greenfield LJ (ed).
Surgery: Scientific Principles and Practice (2nd ed). Philadelphia: Lippincott-Raven, 1997, pp. 309-317; with permission.)
In the same study cited above, Roon and Christensen stated correctly, from an anatomic standpoint, that either high or low injuries can involve vessels
where proximal and distal control is difficult. They advised immediate exploration.
Roden and Pomerantz 6 also advised early operation (neck exploration) for penetrating wounds of the neck. However, Atteberry et al.7 found physical examination
alone to be safe and accurate for evaluation of vascular penetrating injuries in zone II of the neck.
However, Biffl et al.8 stated that selective management of penetrating neck injuries is safe and does not require routine diagnostic testing for asymptomatic
patients with injuries in zones II and III.
We quote from Bumpous et al.9 on penetrating injuries of the visceral compartment of the neck:
Zone II of the anterior neck was the most commonly injured area, with the trachea (69%), esophagus (38%), and larynx (31%) the most commonly
injured structures. Although 31% underwent angiograms, only 13% showed vascular injuries. Eighty-one percent of the patients had injuries involving
more than 1 major structure of the neck. Neck exploration was performed in 81% of the patients and tracheostomies in 75% as well as repair of the
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more than 1 major structure of the neck. Neck exploration was performed in 81% of the patients and tracheostomies in 75% as well as repair of the
trachea (50%), larynx (31%), and esophagus (38%). There is significant mortality associated with these injuries...and many of the patients have longterm sequelae such as dysphagia, hoarseness, and prolonged tracheostomy.
For the evaluation of penetrating neck injuries, Demetriades et al.10 concluded that physical examination and color-flow Doppler imaging are the diagnostic
tools of choice for the physician. They presented an algorithm for the evaluation of these injuries (Fig. 1-11).
Fig. 1-11.
Algorithm for evaluation of penetrating neck injuries. (From Demetriades D, Theodorou D, Cornwell E, Berne TV, Asensio J, Belzberg H, Velmahos G, Weaver F, Yellin
A. Evaluation of penetrating injuries of the neck: prospective study of 223 patients. World J Surg 1997;21:41-48; with permission.)
Britt and Cole11 recommend a paradigm for penetrating neck injuries (Fig. 1-12).
Fig. 1-12.
Penetrating neck injuries management guideline. GSW, gunshot wound; SW, stab wound; HVI, high-velocity injury; *, controversial approach. (From Britt LD, Cole FJ.
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Penetrating neck injuries management guideline. GSW, gunshot wound; SW, stab wound; HVI, high-velocity injury; *, controversial approach. (From Britt LD, Cole FJ.
"Alternative" surgery in trauma management. Arch Surg 1998, 133:1177-1181; with permission.)
Topographic Anatomy of the Neck
The topography of the neck lends itself to description by using a series of natural triangular areas, beginning with the division of the neck into anterior and
posterior cervical triangles, and then by division of these into smaller triangular regions.
The Anterior Cervical Triangle
BOUNDARIES
The boundaries are:
Lateral: sternocleidomastoid muscle
Superior: inferior border of the mandible
Medial: anterior midline of the neck
This large triangle may be subdivided into four more triangles: the submandibular, carotid, muscular, and submental (Fig. 1-13).
Fig. 1-13.
The anterior triangle of the neck is divided into four smaller triangles by the digastric and omohyoid muscles. SCM, sternocleidomastoid muscle. (Modified from
Skandalakis JE, Gray SW, Rowe JS Jr. Surgical anatomy of the submandibular triangle. Am Surg 1979;45:590-596; with permission.)
SUBMANDIBULAR TRIANGLE
The submandibular triangle is demarcated by the inferior border of the mandible above and the anterior and posterior bellies of the digastric muscle below.
Sarikcioglu et al.12 reported an anomalous digastric muscle with three accessory bellies and one fibrous band (Fig. 1-14).
Fig. 1-14.
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Schematic drawing of an anatomic anomaly. 1, anterior belly of digastric muscle; 2, posterior belly of digastric muscle; 3, accessory belly; 4, fibrous band. (Modified
from Sarikcioglu L, Demir S, Oguz N, Sindel M. Anomalous digastric muscle with three accessory bellies and one fibrous band. Surg Radiol Anat 1998;20:453-454; with
permission.)
The largest structure in the triangle, and the most frequent object of the surgeon's attention, is the submandibular salivary gland. Near the end of the sixth
week (slightly later than the parotid gland), it develops from the oral ectoderm. It forms as a solid primordium, becoming canalized later.
Several vessels, nerves, and muscles also are found in the triangle. For the surgeon, the contents of the triangle are best described in four layers, or surgical
planes, starting from the skin. It must be noted that severe inflammation of the submandibular gland can destroy all traces of normal anatomy. In such
instances, identifying and sparing the essential nerves becomes a great challenge.
First Surgical Plane: The Roof of the Submandibular Triangle
The roof of the submandibular triangle is composed of skin, superficial fascia enclosing the platysma muscle and fat, and the underlying mandibular and
cervical branches of the facial nerve (VII) (Fig. 1-15). The mandibular and cervical branches of the facial nerve arise from the cervicofacial division of the
facial nerve. This, the lower division of the facial nerve, passes lateral to the retromandibular (posterior facial) vein within the substance of the parotid gland
in more than 90% of cases;13 in others, it passes medial to the vein. A line drawn from the intertragic notch of the ear, intersecting the midpoint of a line
between the angle of the mandible and the lowest part of the ear, will lie close to the position of the cervicofacial division of the facial nerve.
Fig. 1-15.
The first surgical plane of the submandibular triangle. The platysma lies over the mandibular and cervical branches of the facial nerve. (Modified from Skandalakis JE,
Gray SW, Rowe JS Jr. Surgical anatomy of the submandibular triangle. Am Surg 1979;45:590-596; with permission.)
Remember
The skin should be incised 4 to 5 cm below the mandibular angle.
The platysma and fat compose the superficial fascia.
The mandibular (or marginal mandibular) branch of the facial nerve (VII) lies just below the angle, superficial to the facial artery. Savary et al.14 after studying 10
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The mandibular (or marginal mandibular) branch of the facial nerve (VII) lies just below the angle, superficial to the facial artery. Savary et al.14 after studying 10
fresh cadavers and 1 embalmed cadaver, found several marginal branches, particularly the intermediate ramus, which can form a neural plexus around the facial
artery. Basar et al.15 reported that the marginal mandibular branch of the facial nerve was single in 14 facial halves, consisted of two major branches in 24 facial
halves, and had multiple major branches in 2 halves.
Cervicofacial Division of the Facial Nerve. The nomenclature and topography of the branches of the facial nerve are confusing and variable. The mandibular
(marginal mandibular) nerve is usually the first branch of the cervicofacial division of the facial nerve. In all individuals, this branch crosses superficial to the
facial vein within 2 cm beneath the angular notch of the mandible, wherein the facial vessels can be palpated. From this position it ascends toward the angle
of the lips so that anterior to the position of the facial artery it crosses the lower border of the mandible to supply the muscles of the corner of the mouth
and lower lip.
The curved course of this nerve and the similarly shaped courses of other nerves in this region have led to the term "neural hammocks." The mandibular nerve
forms the first of such hammocks of the submandibular triangle. Skandalakis et al. saw this hammock hanging so far below the mandible that a high
transverse incision would have severed it.16
The mandibular branch of the facial nerve always passes posterior to the angle of the mandible. It lies between the platysma and the deep cervical fascia
(general investing layer), and proceeds to supply the quadratus labii inferioris muscle.
The cervical branch of the facial nerve divides to form descending and anterior branches. The descending branch innervates the platysma and communicates
with the transverse cervical (C2, C3) and great auricular (C2, C3) cutaneous nerves of the neck. The anterior branch, the ramus coli mandibularis, crosses
the mandible superficial to the facial artery and vein, and joins the mandibular branch to contribute to the innervation of the muscles of the lower lip. This
anterior branch forms the second neural hammock of the triangle. It is frequently confused with the mandibular hammock.
Injury to the mandibular branch of the facial nerve results in a very slight drooping of the corner of the mouth. The drooping is not noticeable when the
mouth is in repose –only when it is in motion (smiling). Depending on the nature of the injury, the drooping may be neuropraxia or permanent. Remember that
the orbicularis oris and the muscles innervated by buccal branches actually raise the commissure on the affected side. Injury to the anterior cervical branch
produces minimal drooling that will disappear in 4 to 6 months.
Skandalakis et al.16 measured the distance between these two neural hammocks and the lower border of the mandible in 40 cadavers (80 cervicofacial
dissections). These measurements are shown in Fig. 1-16. In 50 percent of the specimens, the mandibular branch was above the mandibular border and thus
outside the boundaries of the submandibular triangle. In a similar study, Dingman and Grabb17 found the branch to be above the border in 81 percent of their
specimens. If the skin incision is placed at least 4 cm below the border of the mandible, even an exceptionally low cervical branch will not be accidentally
cut.
Fig. 1-16.
The neural "hammocks" formed by the mandibular branch (upper) and the anterior ramus of the cervical branch (lower) of the facial nerve. The distance below the
mandible is given in centimeters. Percentages indicate the frequency of the configuration in 80 dissections of these nerves. (From Skandalakis JE, Gray SW, Rowe JS
Jr. Surgical anatomy of the submandibular triangle. Am Surg 1979;45:590-596; with permission.)
A study of Chinese adults demonstrated that in 67% the marginal mandibular branch ran above the lower border of the mandible, suggesting the existence of
ethnic variations in the topography of the nerve branches.18
Second Surgical Plane: The Contents of the Submandibular Triangle
The structures of the second surgical plane, from superficial to deep, are the facial (anterior facial) vein, the retromandibular (posterior facial) vein, part of
the facial (external maxillary) artery, the submental branch of the facial artery, the superficial layer of submaxillary fascia (deep cervical fascia), the lymph
nodes, the deep layer of submaxillary fascia (deep cervical fascia), and the hypoglossal nerve (XII) (Fig. 1-17).
Fig. 1-17.
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The second surgical plane of the submandibular triangle. The superficial portion of the gland is exposed. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Surgical
anatomy of the submandibular triangle. Am Surg 1979;45:590-596; with permission.)
The retromandibular vein, formed by the union of the superficial temporal and maxillary veins, divides near the angle of the mandible into anterior and
posterior divisions. The posterior division joins the posterior auricular vein to form the external jugular vein. The anterior division passes forward to join the
facial vein, which is inferior to the mandibular notch, thereby forming the common facial vein.13
It is necessary to remember that the facial artery pierces the stylomandibular ligament. This ligament, which most often is thick but sometimes is thin,
extends from the styloid process to the angle of the mandible, with occasional extensions to the stylohyoid muscle and the posterior belly of the digastric
muscle. The ligament is a particularly thickened portion of the deep layer of the fascial capsule of the parotid, which is derived from the superficial investing
lamina of the deep fascia of the neck; it separates the parotid and submandibular glands. Jovanovic 19 described this ligament, emphasizing its importance in
clinical and surgical anatomy. It must be ligated before it is cut to prevent bleeding after retraction. Also, it is important to remember that the lymph nodes
lie within the envelope of the submandibular fascia, in close relationship with the gland, and that nodes occur along facial vessels (this is important in treating
metastatic skin cancers). Differentiation between glands and lymph nodes may be difficult.
The facial vein and the anterior division of the retromandibular vein cross the triangle in front of the submandibular gland, and unite close to the angle of the
mandible to form the common facial vein. The common facial vein empties into the internal jugular vein near the greater cornu of the hyoid bone. It is wise to
identify, isolate, clamp, and ligate both the facial vein and the anterior division of the retromandibular vein.
The facial artery, a branch of the external carotid artery, enters the submandibular triangle under the posterior belly of the digastric muscle and under the
stylohyoid muscle. At its entrance into the triangle, it is under the submandibular gland. After crossing the gland posteriorly, the artery passes over the
mandible, always lying under the platysma. It can be ligated easily.
Third Surgical Plane: The Floor of the Submandibular Triangle
The structures of the third surgical plane, from superficial to deep, include the mylohyoid muscle with its nerve, the hyoglossus muscle, the middle constrictor
muscle covering the lower part of the superior constrictor muscle, and part of the styloglossus muscle (Fig. 1-18).
Fig. 1-18.
The third surgical plane of the submandibular triangle. The superficial portion of the gland has been removed and the deep portion is visible under the edge of the
mylohyoid muscle. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Surgical anatomy of the submandibular triangle. Am Surg 1979;45:590-596; with permission.)
Mylohyoid Muscle. According to DuPlessis,20 the mylohyoid muscles are considered to form a true diaphragm for the floor of the mouth, with the geniohyoid
muscle and the muscles of the tongue above, and the anterior bellies of the digastric muscles and a major portion of the submandibular gland below. The
mylohyoid arises from the mylohyoid line of the inner surface of the mandible; its more posterior part inserts on the body of the hyoid bone, and its more
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anterior part inserts with the opposite mylohyoid into the midline raphe between the hyoid bone and the mandible. The superior surface of the mylohyoid is in
relationship with the lingual and hypoglossal nerves.
Sehirli and Çavdar21 reported a case of a left accessory mylohyoid muscle, located between the anterior belly of the digastric and the normal mylohyoid
muscles. The left accessory mylohyoid muscle extended from the mylohyoid line of the mandible to the lower part of the mylohyoid raphe and hyoid bone.
Hyoglossus Muscle. The thin and quadrilateral hyoglossus muscle arises from the greater horn and body of the hyoid bone. It ascends almost vertically into
the side of the tongue between the styloglossus muscle laterally and the inferior longitudinal musculature of the tongue. The hypoglossal nerve and its venae
comitantes enter the floor of the mouth over the posterior edge of the mylohyoid, lateral to the hyoglossus. From its origin in the neck, the lingual artery
passes deep to the hyoglossus muscle. It enters the floor of the mouth between the hyoglossus muscle laterally and the genioglossus muscle medially.
The nerve to the mylohyoid, which also supplies the anterior belly of the digastric, arises from the inferior alveolar branch of the mandibular division of the
trigeminal nerve. The mylohyoid nerve lies on the inferior surface of the muscle, between it and the digastric. The submandibular space can be thought of as
the combination of the sublingual and submaxillary spaces.
Middle Constrictor Muscle. The middle constrictor originates from the angle between the lesser and greater horns of the hyoid bone and from the stylohyoid
ligament. Its insertion is the median raphe. The fibers travel backward, with the highest ascending and overlapping the superior constrictor, and the lowest
fibers traveling down under the inferior constrictor.
Styloglossus Muscle. The styloglossus muscle has two origins and two insertions. The origins are from the front area of the styloid process and from the
stylomandibular ligament. Insertions are into the side of the tongue and at its inferior area.
Submandibular Space and Ludwig's Angina. The sublingual and submaxillary spaces, above and below the mylohyoid muscle, respectively, are continuous at
the posterior border of the mylohyoid. These spaces can be involved in the diffuse inflammation (cellulitis) of Ludwig's angina, which often results from
infections of the lower molar teeth, most commonly with streptococcus hemolyticus as the infectious agent. As noted by Lindner,22 the entire submandibular
space is bounded tightly by the attachments of the cervical investing fascia to the mandible, the mucous membrane of the floor of the mouth, the
attachment of cervical fascia to the hyoid bone, the hyoid bone itself, and the fascial investment of the posterior belly of the digastric. Edema here, and the
swollen and displaced tongue can cause asphyxiation. Infection of the submandibular space can spread posteriorly along the styloglossus muscle into the
pharyngomaxillary space. From this region, the process can pass into the retropharyngeal space and then inferiorly into the superior mediastinum.
Remember, in Ludwig's angina (as urged by Lindner22):
Cellulitic areas should not be incised. Incisions invite additional foreign organisms into an area that frequently (and early) becomes gangrenous.
Cellulitis should be met with systemic treatment with specific antibiotic therapy, and with local treatment with massive hot compresses and hourly hot saline
gavages to the oral cavity. Intravenous therapy should be used to maintain fluid and electrolyte balances.
To avoid asphyxiation, maintenance of an adequate airway is of utmost importance. Tracheotomy is imperative if the breathing becomes shallow and rapid.
Surgical division of the fascia and mylohyoid is performed only for complications such as drainage of pus under tension, erosion of cervical vessels by the infectious
process, and internal jugular vein thrombosis.
Fourth Surgical Plane: The Basement of the Submandibular Triangle
The structures of the fourth surgical plane, or basement of the triangle, include the deep portion of the submandibular gland, the submandibular (Wharton's)
duct, the lingual nerve, the sublingual vein, the sublingual gland, the hypoglossal nerve (XII), and the submandibular ganglion (Fig. 1-19). The uncinate part
of the submandibular gland rounds the posterior border of the mylohyoid to lie in the connective tissue above it. Here, the submandibular duct arises and
passes through the floor of the mouth to end at the sublingual caruncle beside the frenulum of the tongue anteriorly.
Fig. 1-19.
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The fourth surgical plane of the submandibular triangle. The deep portion of the gland and duct are exposed. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr.
Surgical anatomy of the submandibular triangle. Am Surg 1979;45:590-596; with permission.)
The submandibular duct lies below the lingual nerve (except where the nerve passes under it) and above the hypoglossal nerve.
Lymphatic Drainage
The submandibular lymph nodes receive afferent channels from the submental nodes, the oral cavity, and the anterior parts of the face. Efferent channels
drain primarily into the jugulodigastric, jugulocarotid, and juguloomohyoid nodes of the chain accompanying the internal jugular vein (deep cervical chain). A
few channels pass by way of the subparotid nodes to the spinal accessory chain.
The contents of the submandibular triangle are cleared out during radical neck dissection by removing the submandibular (submaxillary) gland and its envelope
and lymph nodes within, and by removing its capsule and all surrounding tissue without.
SUBMENTAL TRIANGLE
Boundaries
The boundaries of this triangle are:
Lateral: anterior belly of the digastric muscle
Inferior: hyoid bone
Medial: midline
Floor: mylohyoid muscle
Roof: skin and superficial fascia
Contents
The submental triangle contains lymph nodes. The contents of this triangle should be sacrificed in radical neck dissection.23
Lymphatic Drainage
The lymph nodes of the submental triangle receive lymph from the skin of the chin, the lower lip, the floor of the mouth, and the tip of the tongue. They send
lymph to the submandibular and jugular chains of nodes.
CAROTID TRIANGLE
Boundaries
The boundaries are:
Posterior: sternocleidomastoid muscle
Anterior: anterior (superior) belly of the omohyoid muscle
Superior: posterior belly of the digastric muscle
Floor: hyoglossus muscle, inferior constrictor of the pharynx, thyrohyoid muscle, middle constrictor of the pharynx, longus capitus muscle
Roof: investing layer of deep cervical fascia
Contents
The carotid triangle contains:
bifurcation of the carotid artery
internal carotid artery (no branches in the neck)
branches of the external carotid artery
– superior thyroid artery (rare)
– posterior auricular artery
– superficial temporal artery
– internal maxillary artery
– occipital artery
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– ascending pharyngeal artery
– sternocleidomastoid artery
– lingual artery (occasional)
– external maxillary artery (occasional)
– facial artery (occasional)
tributaries of the internal jugular vein
– superior thyroid vein
– pharyngeal vein
vagus nerve
spinal accessory nerve
hypoglossal nerve
ansa hypoglossi
cervical sympathetic trunks (partial)
Protection of nerves and vessels, and removal of the lymphatic tissue is essential.
The posterior belly of the digastric muscle —which is between the submandibular and carotid triangles— is a reliable landmark in a dangerous area. Deep to
the posterior belly, the following anatomic entities will be found:
internal and external carotid arteries
internal jugular vein
glossopharyngeal nerve (9th cranial nerve)
spinal accessory nerve (11th cranial nerve)
hypoglossal nerve (12th cranial nerve)
sympathetic trunk
Lymphatic Drainage
Lymph is received by jugulodigastric, jugulocarotid, and juguloomohyoid nodes, and by nodes along the internal jugular vein from the submandibular and
submental nodes, the deep parotid nodes, and the posterior deep cervical nodes. Lymph passes to the supraclavicular nodes.
MUSCULAR TRIANGLE
Boundaries
The boundaries are:
Superior lateral: anterior belly of the omohyoid muscle
Inferior lateral: sternocleidomastoid muscle
Medial: midline of the neck
Floor: prevertebral fascia and prevertebral muscles; sternohyoid and sternothyroid muscles
Roof: investing layer of the deep fascia; strap, sternohyoid, and cricothyroid muscles
Contents
The muscular triangle contains the thyroid and parathyroid glands, trachea, esophagus, and sympathetic nerve trunk. According to Beahrs,23 this triangle is
the least important.
Remember that occasionally the strap muscles must be cut to facilitate thyroid surgery. They should be cut across the upper third of their length to avoid
sacrificing their nerve supply.
Read an Editorial Comment
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Lymphatic Drainage
Lymphatic drainage of the muscular triangle will be discussed with the thyroid gland.
Posterior Cervical Triangle
The posterior cervical triangle is sometimes considered to be two triangles —the occipital and the subclavian— which are divided by the posterior (inferior)
belly of the omohyoid muscle (Fig. 1-20). We will treat it as one entity.
Fig. 1-20.
The posterior triangle of the neck. The triangle may be divided into two smaller triangles by the omohyoid muscle. (Modified from Skandalakis JE, Gray SW, Rowe JS
Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
BOUNDARIES
The boundaries are:
Anterior: sternocleidomastoid muscle
Posterior: anterior border of the trapezius muscle (Fig. 1-21)
Inferior: clavicle
Roof: superficial investing layer of the deep cervical fascia
Floor: prevertebral fascia and muscles, splenius capitus muscle, levator scapulae muscle, and three scalene muscles
Fig. 1-21.
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The floor of the posterior triangle.
CONTENTS
Between the investing fascia and the prevertebral fascia are the accessory nerve (XI) and a portion of the external jugular vein. Variably deep within the
triangle are the subclavian artery, subclavian vein, cervical nerves, brachial plexus, phrenic nerve, accessory phrenic nerve, spinal accessory nerve, and
lymph nodes.
LYMPHATIC DRAINAGE
Superficial occipital lymph nodes receive lymph from the occipital region of the scalp and the back of the neck. Efferent vessels pass to a deep occipital
lymph node (or occasionally to more than one node) which drains into deep cervical nodes along the spinal accessory nerve.
SURGICAL NOTES
The following are surgical points to remember for the upper or occipital part of the posterior triangle:
Clear the lymph nodes around the spinal accessory nerve very carefully.
Sacrifice the nerve if it is absolutely necessary.
Surgical points for the lower or subclavian part of the posterior triangle:
Be careful with the triangle's contents: the subclavian vein, portions of the transverse cervical vessels, and lymph nodes.
Surgical Applications of the Cervical Triangles
ANTERIOR TRIANGLE
In the past, inflammatory processes in the neck, such as Ludwig's angina, presented with severe mortality and morbidity. Although these inflammatory processes
still occur, they are far less common, with lower mortality, because effective antibiotics arrest and cure the inflammation.
Do not confuse the carotid sinus and the carotid body. Anatomically, the carotid sinus is a dilated area that is usually located at the beginning of the internal carotid
artery. There, the media is thin and poor in muscle. But the adventitia is thick; it is rich with elastic tissue, receptors, and sensory nerve fibers from the
glossopharyngeal nerve.
The carotid sinus (Fig. 1-22) acts as a baroreceptor, responding reflexively to changes in arterial pressure. Elevation of pressure or compression of the
carotid sinus can result in slowing of the heart rate, a sudden fall in arterial pressure, cerebral ischemia, and ipsilateral and secondary syncope.
Fig. 1-22.
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Diagram of the carotid sinus, carotid body, and their innervation. What part the carotid branch of the vagus plays in this innervation is not known. Note that the
carotid body lies not so much in, as medial to, the carotid bifurcation.
The carotid body (Fig. 1-22) is a tiny bilateral lobular anatomic entity 2 to 7 mm in size. It is located at the carotid bifurcation or on the posterior medial side
of the common carotid artery.24 It may be partially embedded in the carotid adventitia from which it developed embryologically. It is composed of a fibrous
capsule with septae which divide it into lobules composed of epithelioid glomus cells, supporting cells, and sinusoids. Tumors of the carotid body may develop
and present serious surgical problems, particularly with regard to hemorrhage during surgery.
The carotid body is a chemoreceptor which is sensitive to low levels of oxygen, high levels of carbon dioxide, or hydrogen ion concentrations. It responds to
these by reflexively increasing respiratory ventilation via its connections with the brainstem. Its nerve supply is derived principally from the glossopharyngeal
nerve, although it also seems to receive fibers from the vagus.
POSTERIOR TRIANGLE
The subclavian artery can be compressed against the first rib by pressure of the thumb placed in the supraclavicular fossa when the hand is grasping the neck.
One of the most common fractures is that of the clavicle, perhaps due in part to the fact that the middle one-third of the clavicle is not protected by muscular
attachments. The subclavius muscle does not have the power to protect the clavicle.
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The accessory nerve (XI) divides the posterior triangle into two nearly equal parts. Borrowing from the terminology of Grant and Basmajian,25 we refer to the upper
area as "carefree," and the lower area as "careful." The position of the accessory nerve in the posterior triangle can be ascertained as follows. First, place a point on
the anterior border of the trapezius one third of the distance between the acromion process and the back of the skull. Second, place a point on the posterior border
of the sternocleidomastoid, two-thirds of the distance from the clavicle to the mastoid process. A line drawn between the two points will lie over the course of the
accessory nerve, deep to the investing fascia. Erb's point, where the external jugular crosses the posterior border of the SCM, emphasizes the exit of the greater
auricular nerve along with cranial nerve XI.
We quote from Kierner et al.26 on the anatomy of the spinal accessory nerve (SAN) and the trapezius branches of the cervical plexus:
(1) The SAN can be found medial as well as lateral to the internal jugular vein, depending how far cranial in the neck it is identified. The crossing
between these 2 important structures can happen only dorsally (44%) or ventrally (56%) to the internal jugular vein...
(2) When the SAN passes through the sternocleidomastoid muscle, it takes an S-shaped, 3-dimensional course instead of running straight through the
muscle...If the nerve were followed through the muscle...the communicating branch(es) with the cervical plexus would obviously be cut.
(3) The cervical plexus branches passing to the trapezius muscle are always subfascial because another relationship to the fasciae of the neck whether superficial or deep - is anatomically impossible.
(4) The SAN can easily be mixed up with the minor occipital nerve because the latter sometimes takes a similar course, turning upward just slightly
medial to the anterior border of the trapezius muscle...Therefore, the supposed SAN must be followed right to the anterior border of the trapezius
muscle to be sure that it keeps its craniocaudal direction. Furthermore, we found that measuring at the posterior border of the sternocleidomastoid
muscle from the clavicle provides the most reliable results and that the nerve can always be identified. The other landmarks cited in the literature,
such as the great auricular nerve or the sternocleidomastoid muscle itself, show much more variability.
In a few preparations, cutaneous branches of the posterior spinal nerves passed through the tendon plane between the spinous processes of the
vertebral column and the trapezius muscle to reach the skin. However, in contradiction to some former works, they were never found to branch within
the muscle, which would have indicated additional innervation.
The following are descriptions of the anatomic entities (from above downward) within the "careful" areas, as well as some indications about their potential for injury.
– The spinal accessory nerve is closely related to the deep posterior cervical nodes. If an abscess is present in this area, make an incision just through the skin. Use
a hemostat to penetrate and drain the abscess. This method avoids injury to the nerve with resultant wasting of the trapezius and drooping of the shoulder.
– The brachial plexus can be injured in the lower part of the triangle by such diverse means as stab wounds, bullets, excessive abnormal traction at childbirth, falls
upon the shoulder, or other sources of blunt trauma.
– The subclavian artery and the brachial plexus can be compressed as they cross the first rib posterior to the anterior scalene muscle.
– The phrenic nerve passes inferiorly on the ventral surface of the anterior scalene muscle beneath the covering of the prevertebral fascia. Because this fascia is
drawn distally as the axillary sheath upon the brachial plexus and axillary artery, anesthetics injected into the sheath can affect the phrenic nerve, resulting in a
hemiparalysis of the diaphragm.
The topographic pathway and relations of the phrenic nerve with other anatomic entities in the neck:
1. Posterior to the inferior belly of the omohyoid muscle, very close to its intermediate tendon
2. Posterior to the internal jugular vein, transverse cervical, and suprascapular arteries
3. Posterior to the thoracic duct on the left neck
4. Anterior to the subclavian artery
5. Posterior to the subclavian vein
We quote from Kline et al.27:
The surgeon can feel the characteristic rounded anterior border of the scalenus anticus as he or she palpates through the fat and lymphoid tissue.
This is an important clue, as the novice tends to operate too far laterally and superiorly, thereby missing the brachial plexus altogether. The surgeon
can clear down to the anterior border of the scalenus anticus with dispatch, knowing that the phrenic nerve is deep to the prevertebral fascia at this
point. Once the phrenic nerve has been dissected free and guarded, the scalenus anticus can be divided after the surgeon has seen that the
subclavian artery is free from its posterior surface.
NOTE: At that point, the phrenic nerve enters the thoracic cavity, anterior to the internal thoracic artery and to the pulmonary hilum, between the
mediastinal pleura and the pericardium. Here the pericardiophrenic vessels are fellow travelers of the phrenic nerve.
The cervical pleura and the apical parts of the lungs extend upward above the clavicle into the root of the neck. Scalene lymph node biopsy can produce iatrogenic
pneumothorax or injury to the apex of the lung, as well as injury to the highest part of the left thoracic duct.
The external jugular vein passes downward from the area of the angle of the mandible to the middle of the clavicle. Just above the clavicle, the vein pierces the
investing fascia and drains into the subclavian vein. In this area, a penetrating neck wound with division of the vein can allow air to be sucked into the vein because
the deep fascia is fixed firmly to the venous wall, thereby keeping the lumen of the vein open. During inspiration a fatal air embolism may take place.
Remember, there are three topographic features in the vicinity of the supraclavicular triangle region of the "careful" part of the posterior triangle. The interscalene
groove and the supraclavicular fossa are present within the triangle; the infraclavicular fossa is located just under the middle one-third of the clavicle, outside of the
posterior triangle (Figs. 1-23, 1-24).
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Fig. 1-23.
The supraclavicular fossa, the infraclavicular fossa, and the jugular fossa.
Fig. 1-24.
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Compression of the subclavian artery and brachial plexus. A, muscle is relaxed; B, contraction of the anterior scalene muscle in the presence of a cervical rib can
produce compression of the subclavian artery and brachial plexus; C, scalenotomy alone may relieve this compression by allowing the vessel and nerves to drop
forward.
– Interscalene Groove: If the head is turned strongly to the opposite side, a triangle is formed by the clavicle inferiorly, the sternocleidomastoid muscle medially, and
the anterior border of the trapezius muscle laterally. The anterior and middle scalenes lie in the floor of this triangle. In different individuals, the groove between them
can be palpated with varying ease.
The position of the cricoid cartilage can be used to approximate the level of the 6th cervical vertebra. Likewise, Chassaignac's tubercle of the transverse process of
C6 can be palpated just behind the posterior border of the sternocleidomastoid. A point located in such fashion in the middle of the triangle approximates the site of
the passage of the subclavian artery and the emerging of the brachial plexus from between the anterior and middle scalenes. The second part of the subclavian
artery lies behind the anterior scalene muscle. A finger passed downward palpating in the interscalene groove will usually feel the pulse of the subclavian artery
without difficulty.28
– The Supraclavicular Fossa: The supraclavicular fossa is formed by the lateral (posterior) border of the sternocleidomastoid muscle, the anterior border of the
trapezius, and the proximal one-half or one-third of the clavicle. This is the pressure point of the subclavian artery, which may be palpated between the finger and
the first rib.
– The Infraclavicular Fossa: The infraclavicular fossa is the soft, palpable hollow located inferior to the middle of the clavicle. It is bounded by the pectoralis major,
deltoid, and clavicle. The axillary vein appears deep to the skin, superficial fascia, and clavipectoral fascia. The axillary artery, bounded by elements of the brachial
plexus, is located deep to the axillary vein. The apical and infraclavicular lymph nodes also are found in this fossa.
The anterior scalene muscle arises from the ventral tubercles of the transverse processes of the 4th through the 6th cervical vertebrae. It descends almost vertically
to insert on the scalene tubercle of the first rib, anterior to the groove for the subclavian artery. The middle scalene muscle, the largest of the three scalenes, arises
from the posterior tubercles of the transverse processes of vertebrae C2-C7. It inserts on the first rib between its tubercle and the subclavian artery groove. The
posterior scalene arises from the posterior tubercles of vertebrae C4-C6. It inserts upon the second rib.
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posterior scalene arises from the posterior tubercles of vertebrae C4-C6. It inserts upon the second rib.
Harry et al.29 reported that the commonly described anatomic relationship of the brachial plexus located between the anterior scalene and middle scalene
muscles was found only in 60 percent of cases. The same authors observed the following variations:
– The scalenus minimus muscle was present in 46 percent of instances (Fig. 1-25)
– In 15 percent of cases the anterior scalene muscle was penetrated by fused C5-C6 roots
Fig. 1-25.
Variations seen in relations between scalene muscles and the brachial plexus. A, subclavian artery piercing the anterior scalene muscle belly; B, roots of C5 & C6
piercing the anterior scalene muscle belly. (Modified from Harry WG, Bennett JDC, Guha SC. Scalene muscles and the brachial plexus: anatomical variations and their
clinical significance. Clin Anat 1997;10:250-252; with permission.)
The subclavian vein crosses the first rib ventral to the anterior scalene, where it is closely associated with, and often compressed by, the subclavius muscle.
Frequently, individuals thus affected have spontaneous or effort-related upper extremity axillary and subclavian venous thrombosis (Paget-von Schroetter
syndrome), unrelated to intercurrent illness or iatrogenic manipulation. Patients with this problem can be treated with a combination of thrombolytic agents
and anticoagulation, resection of the first rib, and balloon angioplasty.30
Thoracic outlet syndrome: The subclavian artery, in company with the brachial plexus and with contributions from cervical nerves C5-C8 and the 1st thoracic nerve,
passes between the anterior and middle scalene muscles. Here the artery and nerves cross the first rib, and can be subject to compression.
Thoracic outlet syndrome actually refers to compression at the upper opening (inlet, superior aperture). Perhaps the use of the word "outlet" is incorrect,
since the lower opening of the thorax is the true "outlet."
The topographic relations of the thoracic inlet:
Posterior: First thoracic vertebral body
Anterior: Superior border of the manubrium of the sternum
Lateral: First rib
We quote from Obuchowski and Ortiz31 on magnetic resonance (MR) imaging of the thoracic inlet:
The borders of the thoracic inlet define an oblique plane that angles downward from the spine anteriorly to the first ribs. It is therefore best to
consider the thoracic inlet as a region or "zone" which extends a short distance above and below this plane to include the lower portion of the
infrahyoid neck and the upper portion of the superior mediastinum. MR's multiplanar imaging capacity allows the thoracic inlet to be subdivided into four
distinct zones: visceral, neurovascular, pulmonary, and spinal.
Post-stenotic dilatation of the subclavian artery can be associated with the development of thrombi. These thrombi, discharged distally into the artery, can
produce confusing symptoms similar to carpal tunnel entrapment of the median nerve. Sanders and Pearce32 observed that 86% of patients suffering from
thoracic outlet syndrome had a history of some form of cervical trauma, especially whiplash injuries. In such individuals, scalenectomy is preferable to
resection of the first rib.
Accessory scalene musculature, fascial bands, or an atypical 7th cervical rib can, variably, compress the artery, the nerves, or both. This compression
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Accessory scalene musculature, fascial bands, or an atypical 7th cervical rib can, variably, compress the artery, the nerves, or both. This compression
results in scalenus anticus (anterior scalene) syndrome, with pain, paresthesia or weakened pulses. During development, the 7th cervical rib forms, and then
normally regresses to its transverse process. Variations in its fate vary from a fully formed rib to rudimentary forms associated with a fibrocartilaginous band.
In a study of 390 transaxillary resections of the first rib for arterial, venous, or brachial plexus compression at the thoracic outlet, Makhoul and Machleder33
found that 66% of the 175 patients had single or multiple abnormalities representing developmental variations: 86 scalene and 39 subclavius muscles were
atypical in form or attachments; 20 scalene muscles were supernumerary; and 17 ribs exhibited abnormalities (7th cervical or atypical 1st thoracic).
In another study of patients suffering from thoracic outlet syndrome, Machleder et al.34 showed that there were demonstrable morphologic transformations of
anterior scalene muscle fibers that reflect metabolic and enzymatic changes characteristic of various adaptive and pathologic processes. In such changes,
attributable to traumatic stress and stretch injury, muscle fibers change from a fast-twitch type 2 fiber to a hypertrophied slow-twitch type 1 fiber. Such
changes occur predominantly in young individuals in response to exercise.
The presence of a cervical rib (found in about 1% of cases) often was shown to be indicative of a variation in the scalene musculature or in the brachial
plexus where the first thoracic nerve had little input, replaced by a major contribution from C4. When the C7 rib was incomplete, the regressed part of the rib
was often replaced by a fibrous band. About 67% of cervical ribs are bilateral. In Makhoul and Machleder's33 study of patients suffering from Paget-von
Schroetter syndrome, 55% had hypertrophy of the tendon of the subclavius muscle as well as enlargement of the insertion tubercle.
Paget-von Schroetter syndrome is frequently associated with thrombosis of the axillary-subclavian vein from exertion, leading to the phrase "effort vein
thrombosis." The condition develops as an abrupt swelling of the upper extremity. According to Flye,35 even with early medical treatment complete resolution
occurs in only 15% to 30% of patients.
Fasciae of the Neck
The following classification of the rather complicated fascial planes of the neck follows the work of several investigators:
Superficial fascia
Deep fascia
– Investing layer (superficial layer)
– Middle, or pretracheal, layer (surrounding the larynx, trachea, and pharynx)
– Prevertebral layer (posterior or deep layer)
Superficial Fascia
The superficial fascia of the neck lies beneath the skin. It is composed of loose connective tissue, fat, the platysma muscle, cutaneous branches of the
cervical plexus, the cervicofacial division of the facial nerve and small cutaneous blood vessels (Fig. 1-26). The surgeon should remember that the cutaneous
nerves of the neck and the anterior and external jugular veins are between the platysma and the deep cervical fascia. If the veins are to be cut, they must
first be ligated. Because of their attachment to the platysma above and the fascia below, they do not retract; bleeding from them can be serious, and the
surgeon must guard against the possibility of production of an air embolism. For all practical purposes, there is no space between this layer and the deep
fascia.
Fig. 1-26.
The superficial fascia of the neck lies between the skin and the investing layer of the deep cervical fascia. CT, connective tissue. (Modified from Skandalakis JE, Gray
SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Deep Fascia
INVESTING LAYER
The superficial (investing) layer of the deep cervical fascia (Figs. 1-26 and 1-27) attaches above to the occipital and temporal bones and the mandible,
posteriorly to the spines and supraspinous ligaments of the cervical vertebrae, and below to the clavicle, scapula, and manubrium of the sternum. It envelops
two muscles —the trapezius and sternocleidomastoid— and two glands —the parotid and submandibular. It forms two spaces —the supraclavicular and
suprasternal; and forms the roof of the anterior and posterior cervical triangles.
Fig. 1-27.
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Fascial layers and spaces above the hyoid bone, in a sagittal section. Note that the "danger space" and the retropharyngeal space show no interruption, but are
continuous with the danger space and the retrovisceral space, respectively, below the level of the hyoid bone. Note also that under normal circumstances, these are
"potential," rather than "actual" spaces. (Based on Hollinshead WH. Anatomy for Surgeons, Vol. 1, 2nd Ed. New York: Harper & Row, 1968.)
PRETRACHEAL LAYER
The middle (pretracheal) layer of the deep fascia (Fig. 1-28) is sometimes described as investing the strap muscles anteriorly, merging with the superficial
investing layer. Conversely, it is also said to be a lamina that passes deep to the strap muscles, uniting with the superficial investing layer lateral to them.36
In keeping with the former view, it is said that a posterior layer of the pretracheal fascia envelops the thyroid gland, forming the false capsule of the gland
(Fig. 1-29). This layer is fixed to the thyroid and cricoid cartilages above. The attachment to the cartilages may be thickened to form the suspensory
ligament of the thyroid gland (ligament of Berry).
Fig. 1-28.
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Fascial layers of the neck. A, Cross section. D, "danger space" within the prevertebral fascia; RV, retrovisceral or retropharyngeal space between the prevertebral
fascia and the pretracheal (visceral) fascial layers. B, Chief fascial layers of the neck below the hyoid bone, in longitudinal section. (A, From Colborn GL, Skandalakis
JE. Clinical Gross Anatomy: A Guide for Dissection, Study, and Review. Pearl River NY: Parthenon, 1993; B, modified from Hollinshead, Anatomy for Surgeons, Vol 1:
The Head and Neck, New York: Harper & Row, 1968; with permission.)
Fig. 1-29.
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The anchor of the thyroid gland: the ligament of Berry.
Posteriorly, the middle cervical fascia becomes ill-defined, permitting an enlarging thyroid gland to extend posteriorly. This posterior, or deep, portion of the
pretracheal fascia can be thought of as the visceral portion of this fascial layer. It is continuous posteriorly with the buccopharyngeal and esophageal
fasciae, as noted some time ago by Grodinsky and Holyoke.37 It is because of this continuity that some prefer the term "visceral layer" to "pretracheal layer,"
as the more appropriate name for the middle layer of deep cervical fascia.
Anteriorly, the middle layer attaches above to the hyoid bone and below to the fibrous pericardium. Laterally, it contributes to the carotid sheath. Posteriorly,
this fascial layer continues as buccopharyngeal fascia to the base of the skull; it terminates inferiorly at about the level of the bifurcation of the trachea by
blending with the alar part of the prevertebral fascia.
PREVERTEBRAL LAYER
The prevertebral (posterior) layer (Fig. 1-27) lies in front of the prevertebral muscles. It originates from the spinous processes and the ligamentum nuchae
posteriorly, and covers the cervical spine muscles, including the scalene muscles and vertebral column anteriorly. At its attachment to the transverse
processes of the cervical vertebrae, the prevertebral fascia divides to form a space in front of the vertebral bodies, the anterior layer being the alar fascia,
the posterior layer retaining the designation of prevertebral fascia.
CAROTID SHEATH
Three fasciae —investing, pretracheal, and prevertebral— compose a fascial tube, the carotid sheath (Fig. 1-28, Fig. 1-30), beneath the sternocleidomastoid
muscle. Within this tube lie the common carotid artery, internal jugular vein, vagus nerve, and deep cervical lymph nodes. In the upper part of the neck, the
connective tissue of the sheath blends with the fascial investments of the stylohyoid muscle and the posterior belly of the digastric. Above this, the sheath
becomes more adherent to the adventitial coverings of the carotid vessels and internal jugular vein.
Fig. 1-30.
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Two views of the visceral compartment of the neck.
Inferiorly, the carotid sheath is adherent to the posterior aspect of the sternum and clavicle and is lateral to the origins of the sternocleidomastoid and strap
muscles. Posteriorly, it is fused with the first rib and Sibson's fascia. In the root of the neck, the visceral fascia passes on to the alar fascia of the carotid
sheath, continuing into the thorax to the fibrous pericardium of the heart and great vessels. As the sheath passes into the thorax, the connective tissue of
the sheath separately encloses each structure within as they diverge from one another.
Behind the carotid sheath, the prevertebral fascia covers the scalene muscles and phrenic nerve, and provides origin for the axillary sheath. The potential
danger space of Grodinsky and Holyoke37 (Figs. 1-27 and 1-28) lies between the alar component and the deeper, muscular part of the prevertebral fascia.
This space provides a plane for the spread of fluids or pathologic processes from the base of the skull to the thoracic diaphragm.
BUCCOPHARYNGEAL FASCIA
The buccopharyngeal fascia (Fig. 1-27) is continuous below with the visceral fascial covering of the esophagus. Superiorly, it covers the posterior and lateral
surfaces of the pharynx and continues forward over the external surface of the buccinator muscle of the cheek. It is joined rather loosely by delicate areolar
tissue to the alar layer of the prevertebral fascia. The interval between the two fascial layers is the retropharyngeal space (Fig. 1-27) which extends
superiorly to the skull base and terminates inferiorly in the upper part of the thorax. This space can be infected by descending infections, by direct
perforations of the esophagus, or by infections of the deep cervical lymph nodes which lie adjacent to it.36
AXILLARY FASCIA
The axillary fascia takes its origin from the prevertebral fascia. It is considered in the chapter on the breast under the heading "Topographic Anatomy and
Relations: Deep Fascia."
Spaces of the Neck
There are many spaces in the neck that are defined by the fasciae (Figs. 1-27, 1-28). Because this book is for the general surgeon, only those spaces that
need special emphasis will be described. Some others, such as the parotid and submaxillary spaces, will be discussed with the organs they are related to. The
authoritative works on the cervical spaces are those of Grodinsky and Holyoke37 and Coller and Yglesias.38
Spaces above the Hyoid Bone
Intrafascial spaces are formed by splitting of the several fascial layers of the neck. The spaces are those related to the body of the mandible, and the submaxillary,
parotid, and masticator spaces.
Peripharyngeal spaces include the retropharyngeal, lateral pharyngeal, and submandibular spaces. Buser and Bart39 studied the normal anatomy of the
retropharyngeal space (Fig. 1-27): this involves the posterior neck in toto from the base of the skull to the level of T1, T2 in the upper mediastinum in front of the
prevertebral fascia and behind the buccopharyngeal or visceral fascia. The lateral pharyngeal space (Fig. 1-31) is a lateral extension of the retropharyngeal space
around the pharynx. The submandibular space (Fig. 1-27) is related to the anterior elements of the several peripharyngeal spaces; it is highly complex.
Fig. 1-31.
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Part of a diagrammatic semifrontal section, slanted somewhat anteriorly from behind the ramus of the mandible, to show the relations of the superficial layer of
fascia to the parotid gland.
Spaces below the Hyoid Bone
The following are the spaces below the hyoid bone (Fig. 1-28A&B, Fig. 1-30):
Visceral compartment (of Stiles)
Carotid sheath (see "Carotid Sheath" under "Deep Fascia" in this chapter)
Space between the prevertebral and alar fasciae, the danger space of Grodinsky and Holyoke 37 (see "Prevertebral Layer" under "Deep Fascia" in this chapter)
The suprasternal space, or space of Burns.
VISCERAL COMPARTMENT
The boundaries of the visceral compartment of the neck (the space of Stiles) (Fig. 1-30) are as follows:
Anterior: Pretracheal fascia
Posterior: Prevertebral fascia
Lateral: Carotid sheath
Superior: Hyoid bone and thyroid cartilage
Posteroinferior: Posterior mediastinum
Anteroinferior: Bifurcation of the trachea, at the level of the 5th thoracic vertebra
The contents of the visceral compartment are the larynx, trachea, thyroid, parathyroid glands, and part of the esophagus.
The lower part of the visceral compartment is subdivided into an anterior pretracheal space and a posterior retrovisceral (retroesophageal) space. These
spaces are separated by lateral attachments of the esophagus to the prevertebral fascia. The spaces are confluent above.37
These spaces of the visceral compartment, together with the carotid sheath, are the chief pathways of infection. Pearse40 stated that in neck infections
that spread to the mediastinum, 71 percent spread through the retrovisceral space, 21 percent through the carotid sheath, and 8 percent through the
pretracheal space.
SUPRASTERNAL SPACE
The suprasternal space (space of Burns) is formed by a splitting of the superficial investing layer of the deep cervical fascia. The anterior lamina is attached
to the anterior surface of the sternum. The posterior lamina is attached to the posterior aspect of the manubrium. Within this space are the lower ends of
the anterior jugular veins and an interconnecting venous arch. Some lymphatic tissue and fatty tissue are often present here as well.
Surgical Applications of the Cervical Fasciae and Spaces
Two abscesses are related to the prevertebral fascia. One is anterior to it, between the fascia and the posterior lateral wall of the pharynx. This is an acute
retropharyngeal abscess (Fig. 1-32). The other is located behind the prevertebral fascia, is secondary to tuberculosis or other osteomyelitis of a cervical vertebra, and
is chronic.
The pretracheal compartment of Stiles is limited above by the hyoid bone, and enters below into the anterior mediastinum. It can be approached surgically by any
kind of incision medial to the sternocleidomastoid and carotid sheath.
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Collections of fluid deep to the prevertebral fascia can track distally down the upper extremity to the level of the elbow by transit within the axillary sheath.
Fig. 1-32.
Chronic and acute retropharyngeal abscesses.
Vascular Supply of the Neck
Despite the fact that we will present the vascular supply of each organ in the neck, at the present time the overall vascular supply will be presented in
summary fashion. The topographic anatomy presented here is based on Montgomery.41
Arteries
COMMON CAROTID ARTERIES
The neck is supplied by the common carotid arteries. The right common carotid arises from the bifurcation of the brachiocephalic trunk and the left common
carotid from the aortic arch (Figs. 1-33, 1-34).
Fig. 1-33.
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Diagrammatic representation of both common carotid arteries (posterior view). (Modified from Montgomery RL. Head and Neck Anatomy: With Clinical Correlations.
New York: McGraw-Hill, 1981; with permission.)
Fig. 1-34.
Common carotid artery and internal and external carotid arteries. (Modified from Montgomery RL. Head and Neck Anatomy: With Clinical Correlations. New York:
McGraw-Hill, 1981; with permission.)
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General Topography
The common carotid artery can be divided arbitrarily into three parts: inferior, middle and superior. The inferior part is behind the sternoclavicular joint on the
right, and is intrathoracic on the left. The middle section is located in the neck. The superior part bifurcates to the internal and external carotid arteries.
In most cases the common carotid artery has no branches in the neck. However, we have often seen the superior thyroid artery arise from the superior part
of the common carotid artery just below and close to the bifurcation, which is the most common location of the carotid body (Fig. 1-35).
Fig. 1-35.
Schema of the embryology, anatomy, and physiology of the carotid body and carotid sinus, and the pathology of the carotid body. (Modified from Singhabhandhu B,
Gray SW, Bryant MF, Skandalakis JE. Carotid body tumors. Am Surg 1973;39:501-508; with permission.)
Remember
The common carotid arteries are enveloped within the carotid sheath together with the internal jugular vein and the vagus nerve.
At its cranial end, the internal jugular vein is ventrolateral to the common carotid artery. More inferiorly, it becomes dorsolateral to the artery.
The vagus nerve is between these two vessels in a posteromedial position.
The vertebral artery normally arises from the first part of the subclavian artery, thereafter passing into the transverse foramen of the 6th cervical vertebra. In about
4% of cases, the left vertebral artery arises directly from the aortic arch. In approximately 6% of cases, the vertebral artery may enter the 7th or 5th transverse
foramen; rarely it enters at even higher levels. The surgical significance of high entry is that in such cases the inferior thyroid artery may pass deep to the aberrant
vertebral artery. This results in a potential for fatal hemorrhage or injury to other structures if the artery is torn while attempting to mobilize the inferior thyroid
artery.
Johnson et al.42 reported that early recurrent stenosis of the carotid artery occurred less frequently after endarterectomy using polytetrafluoroethylene (PTFE)
patch angioplasty than with primary closure or in dacron patch angioplasty.
Relations
Topographically, the origin of the right common carotid is located behind the right sternoclavicular joint. The origin of the left common carotid is
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intrathoracic; as it enters the root of the neck, it passes posterior to the left sternoclavicular joint. At that level the two common carotid arteries are 2½ 3½ cm apart, separated by the trachea. From that point, both carotid arteries have a length of 8-12 cm, terminating at the level of the 4th cervical vertebra
and at the superior level of the thyroid cartilage. There they bifurcate to the external and internal carotid arteries. The larynx separates them from one
another at 5½ - 6½ cm. The surface anatomy of the common carotid can be outlined by a line drawn from the sternoclavicular joint to the neck of the
mandible posteriorly. In each triangle, the pathway of the common carotids is different.
In the region of the muscular triangle, a hypertrophic thyroid gland will cover the common carotid artery; the middle thyroid vein crosses anterior to the
artery. To explore the artery in this area, the platysma muscle and the superficial investing layer of the deep cervical fascia should be incised, the
sternocleidomastoid muscle should be retracted medially, and the infrahyoid muscles and their fasciae should also be incised.
At the carotid triangle the artery has anterior, posterior and medial relations of importance. Anteriorly, the platysma muscle and the superficial investing layer
of the deep cervical fascia cover the artery; there, above the omohyoid muscle, the carotid is crossed by the superior thyroid artery and vein and its
sternocleidomastoid branch.
The posterior relations are as follows:
Retropharyngeal space
Prevertebral fascia
Cervical sympathetic nerves and ganglia
Longus coli muscle
Longus capitis muscle
Anterior tubercles of the transverse processes of the 4th, 5th, 6th, and 7th cervical vertebrae
Vertebral artery and vein
Medial to the common carotid are the following anatomic entities:
Lower part of the pharynx
Thyroid cartilage
Cricoid cartilage
Lateral aspect of the thyroid lobe
Branches of the inferior thyroid artery
Recurrent laryngeal nerve
Esophagus
Trachea
At the right sternoclavicular joint, the common carotid is medial to the internal jugular vein. The left carotid is behind the internal jugular vein. The thoracic
duct is located dorsal to the artery on the left. The right recurrent laryngeal nerve crosses the dorsal side of the first part of the right common carotid
artery.
Variations of the great arteries of the carotid triangle were studied by Lucev et al.43 in an excellent paper that we recommend to the interested student.
Collateral Circulation
According to Montgomery,41 collateral circulation of the common carotid artery (Fig. 1-36) is carried on chiefly by:
Anastomosis of the internal carotid of one side with the internal carotid of the opposite side and with both vertebral arteries through the cerebral arterial circle
Anastomosis of the inferior thyroid with the superior thyroid
Anastomosis of the deep cervical branch of the costocervical trunk with the descending branch of the occipital
Anastomosis of the superior thyroid, lingual, facial, occipital, and temporal with corresponding arteries of the opposite side
Anastomosis of the ophthalmic with the angular
Fig. 1-36.
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Some of the collateral channels available after ligation of the common carotid artery. On the right side of the body are shown the chief communications between the
two sides; on the left, the chief longitudinal anastomoses.
INTERNAL CAROTID ARTERY
The internal carotid artery (Fig. 1-37) is located within the carotid triangle, under and deep to the stylohyoid muscle and the posterior belly of the digastric
muscle. The internal carotid does not give origin to any branches in the neck, since its supply is limited to intracranial structures. It is crossed laterally by the
hypoglossal nerve.
Fig. 1-37.
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Internal and external carotid arteries. (Modified from Montgomery RL. Head and Neck Anatomy: With Clinical Correlations. New York: Mc Graw-Hill, 1981; with
permission.)
An aberrant internal carotid artery was reported by Cole and May44 as a vascular abnormality of the middle ear. These authors were able to collect 45 cases.
Papon et al.45 discussed the existence of anastomoses between the internal carotid and vertebral arteries (or artery) in the neck. These findings suggest a
possible need for modifying surgical technique during endarterectomy. Meder et al.46 reported six cases of segmental agenesis of the internal carotid artery.
Carsten et al.47 recommended Doppler screening examinations to detect asymptomatic carotid stenoses.
EXTERNAL CAROTID ARTERY
General Topography
The external carotid artery begins at the bifurcation of the common carotid artery at C4. It continues upward to a point posterior to the neck of the mandible
(approximately 1.5 cm below the zygomatic arch) where it bifurcates to form the maxillary and superficial temporal arteries. The superior thyroid, lingual, and
facial arteries arise from the ventral aspect near the origin of the external carotid; the ascending pharyngeal, occipital and posterior auricular branches arise
from the dorsal side of the external carotid. The 8 variable branch arteries of the external carotid are: maxillary, superficial temporal, superior thyroid, lingual,
facial, ascending pharyngeal, occipital, and posterior auricular arteries.
Relations
The hypoglossal nerve passes lateral and anterior to the external carotid artery just above the level of the hyoid bone. The external carotid is located
superficially and somewhat anterior and medial to the internal carotid artery. Intervening between the internal and external carotid arteries are several
anatomic entities:
stylopharyngeus muscle
styloglossus muscle
styloid process
glossopharyngeal nerve
pharyngeal branches of the vagus nerve
The anatomy of the branches of the external carotid artery will be discussed with related organs.
SURGICAL APPLICATIONS OF ARTERIAL ANATOMY
Occasionally the external carotid artery may be absent on one or both sides.
The branches of the missing vessels arise from the external or common carotid on the other side.
The internal carotid may be absent rarely.
The common carotid may bifurcate high at the level of the hyoid bone, or lower at the level of the cricoid cartilage.48
Several nerves of the neck are related to the internal carotid artery. It is important to be aware of potential injury to cranial nerves XII and X, especially during
carotid surgery.
Ligation of the external carotid artery can be done with impunity if the internal carotid artery is not injured (Fig. 1-38). The ligation can be done above or below the
origin of the superior thyroid artery if necessary.
Despite abundant collateral circulation of the common carotid artery, unilateral ligation of the artery should never be done unless it is absolutely necessary,
according to Hollinshead 36 (see Fig. 1-36). Ligation of the common carotid artery has been said to reduce the blood flow of the internal carotid artery and, therefore,
the supply to the brain by approximately 50%.36 According to Roberts et al.,49 the external carotid artery also delivers blood to the internal carotid (by virtue of the
anastomoses of the two). But, even if there is no vascular disease, it is sufficient in only 50% of the cases. This occurs because flow tends to be from the internal
carotid to the external carotid (the opposite of that anticipated), thus diverting even more blood flow from the brain.
Ligation of the internal carotid artery should be absolutely avoided (Fig. 1-38). According to Dandy,50,51 there was a death rate of 4% following ligation of the
internal carotid for intracranial aneurysms. Pemberton and Livermore 52 reported a death rate of 15.7% in a study of internal carotid ligations in 51 cases for reasons
other than intracranial aneurysms. They also reported that 30% of patients who had tumors of the carotid body died as a result of ligation of the internal carotid.
Drake et al.53 reported 133 cases of aneurysm arising from the internal carotid artery. They used internal carotid occlusion in 131 cases and common carotid occlusion
in 2, and stated that Hunterian proximal arterial occlusion can be done with safety.
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Fig. 1-38.
Ligation guidelines.
Kuehne et al.54 found that the neurologic outcome after internal carotid artery injury is enhanced by an algorithm based on the liberal use of angiography, a
predefined surgical approach, and selective observation. These authors also do not advocate ligation of the internal carotid artery. The algorithm is as
follows:
1. Hemodynamically stable patients with suspected internal carotid artery (ICA) injuries undergo a diagnostic angiography.
2. Reconstruct surgically accessible injuries regardless of neurologic status, with two exceptions:
a. Neurologically intact patients with ICA occlusion are treated by anticoagulation and mild pharmacological hypertension.
b. Minimal nonocclusive injuries are managed nonoperatively and followed up by serial angiography or duplex ultrasonography.
3. Heparinization, shunting, and completion angiography are employed.
In the discussion section of the article by Kuehne et al.,54 the ability to repair the internal carotid artery was questioned because of the relative
inaccessibility of two-thirds of its length. The authors responded that they had been able to repair the majority of injuries using standard techniques.
The patient with injury of the internal carotid artery may develop hemorrhagic infarction in the reperfused ischemic brain,55 or cerebrovascular morbidity such as
cerebral edema and herniation.54
As reported by Okamoto,56 the only therapy offering any potential cure or palliation in advanced head and neck cancer with involvement of the carotid artery is
resection of the carotid artery.
Marien and Thompson57 report a case of an anomalous occipital artery originating from the cervical internal carotid artery and not from the posterior wall of
the external carotid artery.
Ballotta et al.58 stated that cranial and cervical nerve injury after carotid endarterectomy is a common major or minor complication.
Guterman et al.59 reported that carotid endarterectomy for revascularization of the cervical carotid bifurcation provides a good alternative to open surgery
for patients who are considered at risk for excessive morbidity and mortality.
Veins
INTERNAL JUGULAR VEIN
The internal jugular vein (Fig. 1-39) is the principal vein of the head and neck; it is the downward continuation of the sigmoid sinus. The vein exits the skull,
along with cervical nerves IX, X, and XI, through the jugular foramen. Until it reaches the level of the superior border of the thyroid cartilage, the internal
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along with cervical nerves IX, X, and XI, through the jugular foramen. Until it reaches the level of the superior border of the thyroid cartilage, the internal
jugular vein lies to the external side of the internal carotid artery. Later, it takes a position along the lateral side of the common carotid artery within the
carotid sheath. Finally, close to its termination, it is located anterior to the artery. It is located under the sternocleidomastoid muscle. The veins that empty
into the internal jugular vein will be described with the related organs.
Fig. 1-39.
Internal jugular vein. (Modified from Montgomery RL. Head and Neck Anatomy: With Clinical Correlations. New York: McGraw-Hill, 1981; with permission.)
EXTERNAL JUGULAR VEIN
The external jugular vein passes obliquely and superficial to the sternocleidomastoid muscle deep to the platysma. The external jugular vein begins near the
angle of the mandible, at the junction of the posterior division of the retromandibular vein with the posterior auricular vein.
Erb's point is where the external jugular crosses the posterior border of the sternocleidomastoid; here, the vein is very closely related to several of the
cervical cutaneous nerves. The great auricular nerve and the transverse cutaneous nerve are of particular importance because of their sensory supply to the
lower part of the ear and the lower part of the face in the region of the angle of the mandible. This is also the site of the exit of cranial nerve XI.
In its course, the external jugular vein communicates with the internal jugular and receives a number of tributaries in the neck, including transverse cervical
and suprascapular veins. It usually ends by piercing the superficial investing layer of deep fascia and joining the subclavian vein, although it can also
terminate in the internal jugular.
Remember
The external jugular vein may be ligated with impunity if the internal jugular vein is intact.
Lymphatic Structures of the Neck
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Lymphatic Structures of the Neck
NUMBER OF LYMPH NODES
There is a significant range in the number of lymph nodes believed to be in the neck. Bailey & Love's60 reported that there are about 800 lymph nodes in the
human body, 300 of which are in the neck. In contrast, Gray's Anatomy61 reported that the adult body contains only 400-450 lymph nodes, with 60-70 in
the region of the head and neck.
Carlson stated (personal communication between G.W. Carlson and J.E. Skandalakis, April 22, 1996), "There are many lymph nodes in the first echelon
drainage of the oral cavity and oropharynx that are never surgically removed so I feel that the total number of lymph nodes could be approximately 150 to
300."
Drinker and Yoffey62 wrote that all the lymphoid tissue in the human body (including the lymphocytes in bone marrow) probably corresponds to nearly 1% of
the total body weight. This may equal a mass half the weight of the liver.
LEVELS OF THE NODES
The anatomy and pathology of cervical and retropharyngeal lymph nodes has been evaluated by computed tomography by Mancuso et al.63,64 From a
surgical standpoint, however, the lymph nodes of the neck are divided into 5 groups, or levels. There is no widespread agreement on the nomenclature of
lymph nodes and their division into groups. We consider the system of Healey65 to be the best and the easiest to remember; the "chains" of nodes are shown
in Fig. 1-40. The groups composing these chains are listed in Table 1-2. Some of the nodes of the intermediate vertical chain are shown in Fig. 1-41.
Table 1-2. Lymph Nodes and the Lymphatic Drainage of the Head and Neck
Lymphatics
Location
From
To
Submental nodes
Submental triangle
Skin of chin, lip, floor of mouth, tip of tongue
Submandibular nodes or jugular chain
Submandibular nodes
Submandibular triangle
Submental nodes, oral cavity, face, except
forehead and part of lower lip
Intermediate jugular nodes, deep posterior
cervical nodes
Preauricular (parotid)
nodes
In front of tragus
Lateral surface of pinna, side of scalp
Deep cervical nodes
Postauricular (mastoid)
nodes
Mastoid process
Temporal scalp, medial surface of pinna,
external auditory meatus
Deep cervical nodes
Between mastoid process and external
occipital protuberance
Back of scalp
Deep cervical nodes
Subparotid nodes, jugular chain, occipital, and
mastoid area
Supraclavicular and deep cervical nodes
All other nodes of neck
Lymphatic trunks to left and right thoracic
ducts
Superior horizontal chain:
Occipital nodes
Vertical chain:
Posterior cervical (posterior
triangle) nodes
Superficial
Along exterior jugular vein
Deep
Along spinal accessory nerve
Intermediate (jugular)
nodes
Juguloparotid (subparotid) Angle of mandible, near parotid nodes
nodes
Jugulodigastric
(subdigastric) nodes
Junction of common facial and internal
jugular veins
Jugulocarotid (bifurcation) Bifurcation of common carotid artery
Palatine tonsils
Tongue, except tip
nodes
close to carotid body
Juguloomohyoid
(omohyoid) nodes
Crossing of omohyoid and internal
jugular vein
Tip of tongue
Parapharyngeal nodes
Lateral and posterior wall of pharynx
Deep face and esophagus
Intermediate nodes
Paralaryngeal nodes
Lateral wall of larynx
Larynx and thyroid gland
Deep cervical nodes
Paratracheal nodes
Lateral wall of trachea
Thyroid gland, trachea, esophagus
Deep cervical and mediastinal nodes
Cricothyroid ligament
Thyroid gland, pharynx
Deep cervical nodes
Anterior wall of trachea below isthmus
of thyroid gland
Thyroid gland, trachea, esophagus
Deep cervical and mediastinal nodes
Axilla, thorax, vertical chain
Jugular or subclavian trunks to right
lymphatic duct and thoracic duct
Anterior (visceral) nodes
Prelaryngeal (Delphian)
nodes
Pretracheal nodes
Inferior horizontal chain:
Supraclavicular and scalene Subclavian triangle
nodes
Source: Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.
Fig. 1-40.
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The lymph nodes of the neck from Healey's classification. SH, Superior horizontal chain. IH, Inferior horizontal chain. PV, Posterior vertical chain. IV, Intermediate
vertical chain. AV, Anterior vertical chain. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill,
1983; with permission.)
Fig. 1-41.
Some drainage to lymph nodes of the intermediate vertical (jugular) chain. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General
Surgery. New York: McGraw-Hill, 1983; with permission.)
Level I (Submental and Submandibular Nodes)
Level I consists of all lymph nodes within the submental and submandibular triangles, i.e., between the anterior midline and the anterior border of the
posterior belly of the digastric muscle.
Level II (Upper Jugular Chain)
This level includes all deep jugular lymph nodes in the upper one-third of the neck. Arbitrarily, that area is bounded by the upper one-third of the posterior
border of the sternocleidomastoid muscle and the medial border of the posterior belly of the digastric. The boundary extends above to the occipital area and
below to a line corresponding to the pathway of the great auricular nerve, where it crosses the upper part of the sternocleidomastoid obliquely. The
jugulodigastric (subdigastric) node also belongs to this level.
Level III (Midjugular Chain)
This is a near-triangle formed (below) by the anterior belly of the omohyoid muscle, laterally (posteriorly) by the posterior border of the middle one-third of
the sternocleidomastoid muscle, and medially by the hyoid bone.
Level IV (Lower Jugular Chain)
The boundaries of Level IV consist of the posterior or lateral border of the lower third of the sternocleidomastoid, superiorly of the omohyoid muscle, and
inferiorly of the clavicle. The juguloomohyoid and deep lower jugular lymph nodes are located within this space.
Level V (Posterior Cervical Triangle)
This is the posterior triangle of the neck, which includes the posterior cervical lymph nodes in toto (spinal accessory nodes, inferior horizontal chain, scalene
nodes).
Kraus et al.66 reported a small incidence of supraspinal lymph node metastasis in patients with squamous cell carcinoma of the oral cavity and oropharynx
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with negative lymph nodes.
SPECIAL LYMPH NODES
Virchow's node, also called the signal node, is located just above the middle third of the left clavicle. When sufficiently enlarged and firm enough to be palpable, it is
usually presumptive evidence of malignant neoplasm below the diaphragm.
The Delphian node is found just above the thyroid isthmus.
The neck also contains a number of subepithelial lymphoid structures, the tonsils.
Tonsils
The opening between the nasal and oral cavities and the pharynx is guarded by a group of lymphoid structures collectively referred to as the ring of Waldeyer
(Fig. 1-42).
Fig. 1-42.
The lymphoid structures of the tonsillar ring of Waldeyer surrounding the pharynx. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in
General Surgery. New York: McGraw-Hill, 1983; with permission.)
On the roof of the nasopharynx, at the superior aspect of the ring of Waldeyer, is the pharyngeal tonsil (adenoids). The lingual tonsils are at the inferior
aspect of the ring, on the sides of the base of the tongue. Laterally, the palatine tonsils guard the entrance to the pharynx. There may be a band of
superficial lymph nodules, the lateral band, between the pharyngeal and palatine tonsils. These tonsillar organs differ from lymph nodes in that they provide
origin to, but do not receive, lymphatic vessels; Fig. 1-42 shows the lymph nodes into which they drain.
MASSES IN THE NECK
The human neck is designed such that the swelling of a normal structure or the presence of an abnormal one is readily apparent. Neoplasms and infections
can affect any of the 60-70 lymph nodes or the more than a dozen fascial spaces in the neck. Persistent embryonic structures may occupy spaces no longer
available to them. The structures of the neck are packed so tightly that nearly every lesion expresses itself as a visible or palpable bulge. In most cases,
even the most perfunctory physical examination will reveal the swelling.
Skandalakis et al.67 examined reports of 7,748 neck masses found in 232,256 surgical admissions from 1954 to 1972. Of these, 3,625 were of thyroid origin
(46.8 percent) and 4,123 were of nonthyroid origin (53.2 percent).
With a little rounding of the figures in the above study, two rules became apparent. The rules offer a well-marked pathway to diagnosis of nonthyroid neck
masses.
Rule of 80
The Rule of 80 for Neck Masses is as follows. 80 percent of:
nonthyroid masses are neoplastic
neoplastic masses are in males
neoplastic masses are malignant
malignant masses are metastatic
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metastatic masses are from primary sites above the clavicle
Rule of 7
The Rule of 7 provides a probable diagnosis of the neck mass based on the average duration of the patient's symptoms.
7 days: inflammation
7 months: neoplasm
7 years: congenital defect
AIDS (Acquired Immune Deficiency Syndrome) may have changed these numbers, since most patients will have several other groups of lymph nodes involved,
such as axillary nodes and inguinal nodes. The Rule of 80 and Rule of 7 were based on hospitalized patients with cervical lymphadenopathy. In spite of the
impossibility of such a statistical analysis being duplicated today (most patients with cervical lymphadenopathy are treated as outpatients), the authors think
that both rules remain useful and worth remembering.
The best diagnosis of primary or metastatic head and neck masses is a complete clinical evaluation and biopsy or biopsies. Lyles et al.68 and Feldman et al.69
found fine-needle aspiration reliable and safe in the management of squamous cell carcinoma of the head and neck. Lee et al.70 studied patients with
metastatic squamous carcinoma of the neck and occult primary lesion. They advised thorough evaluation prior to surgery to locate the primary tumors, and
reported that surgery, irradiation, or both can cure about 50% of patients with an unknown primary tumor.
Clonal assay of head and neck tumors was the topic of several papers from the early 1980's. We quote from Johns:71
. . .The clonogenic soft agar assay for head and neck tumor cells is a useful tool for studying their biology and growth characteristics...Ultrastructural
studies are particularly helpful in delineating the characteristics of tumor stem cells and understanding the histogenesis of neoplasms. . . Low cloning
efficiency (<0.005%) was associated with good probability of survival, whereas high cloning efficiency (0.005%) was associated with early recurrence
of cancer or death from the disease.
Johns and Mills72 elaborated on the relationship of vigorous stem cell populations, as measured by cloning efficiency, and the development of recurrences and
metastases in squamous cell carcinomas of the head and neck. Johns et al.73 reported that the human colony-forming assay test contributed to the
understanding of the cellular origins of salivary gland lesions and the chemosensitivities of salivary gland carcinomas.
THORACIC DUCT
The thoracic duct originates from the cisterna chyli and terminates in the left subclavian vein. It is from 38 to 45 cm long. The duct arises at about the level
of the 2nd lumbar vertebra from the cisterna chyli or, if the cisterna is absent (about 50 percent of cases), from the junction of the right and left lumbar
lymphatic trunks and the intestinal lymph trunk.74 It ascends on the right side of the midline on the anterior surface of the bodies of the thoracic vertebrae.
It crosses the midline between the 7th and 5th thoracic vertebrae to lie on the left side, to the left of the esophagus.
The duct passes behind the great vessels at the level of the 7th cervical vertebra, crossing ventral to the vertebral artery, and descends slightly as it
passes behind the common carotid artery to enter the left subclavian vein (Fig. 1-43) at its junction with the left internal jugular vein. The duct may have
multiple entrances to the vein, and one or more of the contributing lymphatic trunks may enter the subclavian or jugular vein independently. It can be ligated
with impunity.
Fig. 1-43.
The thoracic duct and main left lymphatic trunks. Trunks are variable and may enter the veins with the thoracic duct or separately. (Modified from Skandalakis JE,
Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
The thoracic duct collects lymph from the entire body below the diaphragm, as well as from much of the left side of the thorax. Lymph nodes may be present
at the caudal end, but there are none along its upward course. Injury to the duct in supraclavicular lymph node dissections results in copious lymphorrhea,
depletion of body fluids, and loss of proteins and electrolytes. Ligation is the answer.
Wechselberger et al.75 advocate the treatment of chronic thoracic duct fistula using a sternocleidomastoid muscle flap.
RIGHT LYMPHATIC DUCT
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RIGHT LYMPHATIC DUCT
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The right lymphatic duct —a variable structure about 1 cm long— is formed by the right jugular, transverse cervical, internal mammary, and mediastinal
lymphatic trunks (Fig. 1-44). If these trunks enter the veins separately, there is no right lymphatic duct. When present, the right lymphatic duct enters the
superior surface of the right subclavian vein at its junction with the right internal jugular vein. It drains the right side of the head, right upper limb, most of
the right side of the thorax, and the lower two-thirds of the left lung. It is the remnant of the original embryonic system of bilaterally symmetric right and left
thoracic ducts, representing the terminal part of the right thoracic duct.
Fig. 1-44.
The right lymphatic duct is formed by the junction of several lymphatic trunks. If they enter the veins separately, there may be no right lymphatic duct. (Modified from
Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Nerves of the Neck
Although the innervation of some of the anatomic entities of the neck is described in detail in this chapter, we think it is appropriate here to present a brief
summary of the nerves in general.
The nerves of the neck form a peculiar pathway from above downward, traveling all over the neck but with a definite anatomic destiny to supply the vessels
of the head, intracranial area, neck, and upper extremities. The nerves that are responsible for the innervation of some anatomic entities in the neck or other
territories, but originating in the neck, are as follows:
5 cranial nerves (VII, IX, X, XI, XII)
cervical sympathetic nerves
cervical plexus (superficial and deep)
brachial plexus
Five Cranial Nerves
The cranial nerves (VII, IX, X, XI, XII) are covered in detail in several parts of this book, such as the section on parotid glands in this chapter (facial nerve),
in the thyroid section of this chapter and in the stomach chapter (vagus nerve), and several other nerves are covered in the discussion of anatomic
complications of surgery for metastatic disease of the neck in the section on radical neck dissection. The emphasis here will be on the topography of the
ganglia of the sympathetic chain and their branches, rather than on details of the action of this system. Even though knowledge of the system has
increased, there is still much we do not know. Perhaps Sir William Turner was right when he stated, "The sympathetic begins nowhere."76
Cervical Sympathetic Nerves
The sympathetic trunk of the neck is in the prevertebral fascia between the carotid sheath in front and the longus colli and longus capitis muscles behind. It
extends above into the skull as a plexus surrounding the internal carotid artery. It is continuous, downward, with the sympathetic trunk of the thorax.
The cervical sympathetic chain is formed by three ganglia (superior, middle, and inferior) (Fig. 1-45). Each gives grey rami communicantes to the cervical
nerves, a cardiac nerve, and a plexus to an artery.
Fig. 1-45.
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The cervical sympathetic trunk. (Modified from Decker GAG, Du Plessis DJ (eds). Lee McGregor's Synopsis of Surgical Anatomy (12th ed). Bristol, England: John Wright,
1986; with permission.)
The uppermost ganglion, the superior cervical ganglion, is a reddish, flat, ellipsoidal structure. It is the largest of the three ganglia and is located just behind
the sheath of the internal carotid artery. The ganglion rests on the prevertebral fascia in the area of the transverse process of the 2nd and 3rd cervical
vertebrae. The fascia covers the longus capitis muscle.
The superior sympathetic ganglion of the neck gives grey rami communicantes to the first cervical nerves (1 to 4), forms a plexus around the external carotid
artery, gives a branch to the pharyngeal plexus, and finally gives origin to the superior cardiac nerve and the carotid nerve. McGregor and DuPlessis76 stated
that the plexus around the internal carotid artery communicates with the vagus, glossopharyngeal, and hypoglossal nerves.
Topographically the middle cervical ganglion, which is the smallest of the three (about 3 mm in diameter), is located at the level of the 6th cervical vertebra
and the cricoid cartilage. The inferior thyroid artery is an excellent landmark for the topography of this ganglion which is located anterior or posterior to the
artery. We agree with McGregor and DuPlessis that it is always present.
The middle cervical ganglion gives grey rami communicantes to the 5th and 6th cervical nerves, a plexus around the inferior thyroid artery, and the middle
cardiac nerve. It is interconnected to the inferior cervical ganglion.
The inferior cervical ganglion (cervicothoracic or stellate) is situated behind the vertebral artery, and between the transverse process of the 7th cervical
vertebra and the neck of the 1st rib, and medial to the descending branch of the costocervical branch of the subclavian artery. It is larger than the middle
ganglion but smaller than the superior cervical ganglion. It gives grey rami communicantes to C7-C8 cervical nerves; it surrounds as a plexus the subclavian
artery and its branches, and it gives origin to the inferior cardiac nerve. The 1st thoracic and inferior sympathetic ganglia are often united to form the
stellate ganglion.
Kline et al.27 discussed the topographic anatomy of the stellate ganglion:
Ansae or small rootlets enter and leave T1 and can lead the surgeon to the stellate ganglion and then the caudal portion of the thoracic sympathetic
chain. Another landmark is the vertebral artery, which can be found originating from the proximal portion of the subclavian and running upward and
medially toward the tranverse processes of C6. By elevation of the proximal portion of the vertebral artery, the stellate ganglion can usually be found
posterior to it; the rest of the thoracic sympathetic chain can be found inferior to it beneath subclavian vessels and in the upper mediastinum.
SURGICAL APPLICATIONS
Remember
The nodose ganglion (ganglion inferius) of the vagus nerve is close to the superior cervical ganglion. Anson and McVay77 stated that the ganglion should not be
excised unless its sympathetic communicating strand leads to the middle cervical ganglion; this prevents mistaking it for the nodose ganglion of the vagus nerve.
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excised unless its sympathetic communicating strand leads to the middle cervical ganglion; this prevents mistaking it for the nodose ganglion of the vagus nerve.
When the stellate ganglion (ganglion cervicothoracicum) is removed it produces Horner's syndrome (see "Anatomic Complications of Thyroidectomy"). To avoid
Horner's syndrome, carefully dissect the inferior part of the stellate ganglion.77
Removal of the stellate ganglion as well as the 1st, 2nd, 3rd, and maybe the 4th thoracic ganglia (cervicodorsal sympathectomy) is done occasionally for severe
Reynaud's phenomena (vasospastic disease of the upper extremity and severe palmar hyperhidrosis) in the hope that the pain secondary to the vascular spasm will
be alleviated.
Low anterior cervical, transaxillary, or transpleural thoracoscopic approach may be used for cervicodorsal sympathectomy.
The upper pathway of the phrenic nerve is a landmark for the location of the 5th and 6th cervical nerves during neck exploration.
The cervical sympathetic chain is located lateral to the anterior spinal ligament. Occasionally, the thorascopist confuses the ligament with the chain, and will not
perform a cervical sympathectomy. The nerve of Kuntz is a highly variable anatomic entity within the upper thorax. It is located between the root of the first thoracic
and the second thoracic intercostal nerves. The physiologic action of this ramus may relate to the sympathetic chain.78,79
Cervical Plexus
The cervical plexus (Fig. 1-46) is formed by the anterior divisions of the spinal nerves C1-C4 and is located between the middle scalenus muscle and the
levator scapula. It is covered by the SCM muscle. The branches of the cervical plexus consist of two groups: superficial and deep.
Fig. 1-46.
Superficial and deep cervical plexuses. (Modified from Healey JE Jr, Hodge J. Surgical Anatomy. Philadelphia: BC Decker, 1990; with permission.)
The superficial group (Fig. 1-47) is formed by the anterior primary divisions of cervical nerves C2, C3, and C4. The physiologic destiny of this group is
sensory. The following nerves belong to the superficial group and all of them will be seen in the vicinity of the middle part of the posterior border of the SCM
muscle, at which point the superficial plexus exits.
lesser occipital (C2)
great auricular (C2, C3)
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transverse cervical (C2, C3)
supraclavicular (C3, C4)
Fig. 1-47.
Superficial group of the cervical plexus. (Modified from Healey JE Jr, Hodge J. Surgical Anatomy. Philadelphia: BC Decker, 1990; with permission.)
The deep group (Figs. 1-46, 1-48) is motor, innervating the strap muscles of the neck and the skin and diaphragm. The branches are formed by the anterior
divisions of C1-C4 nerves. The deep group consists of the following nerves:
phrenic (C3-C5)
muscular branches to strap muscles: omohyoid, sternohyoid, sternothyroid, thyrohyoid by way of the ansa cervicalis (C1, C2, and C3)
– geniohyoid (C1)
– rectus capitis lateralis (C1)
– rectus capitis anterior (C1)
– longus capitis (C1-C4)
– longus colli (C3-C8)
– scalenus anterior (C4-C6)
– intertransversalis (C1-C8)
sternomastoid (C2, C3, or both)
levator scapulae (C3-C4)
trapezius (C3-C4 probably proprioceptive, with motor supply from XI)
scalenus medius (C3-C7)
Fig. 1-48.
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Deep group of the cervical plexus. (Modified from Healey JE Jr, Hodge J. Surgical Anatomy. Philadelphia: BC Decker, 1990; with permission.)
Brachial Plexus
The brachial plexus is formed by the anterior divisions of the four lower cervical nerves (C5-C8) with participation of the one upper thoracic nerve (T1) (Fig.
1-49). In addition, communications from C4 and T2 may also be present. It is a nerve plexus formed, subsequently, of roots, trunks, divisions, cords, and
terminal nerve branches. The brachial plexus emerges from between the anterior and middle scalene muscles, resting upon the middle scalene. The roots and
trunks are located in the neck and are related to the subclavian artery. To be more specific the plexus is in the posterior triangle of the neck: it is adjacent
to the clavicle, sternocleidomastoid muscle, and anterior scalene muscle; it rests on the middle scalene muscle.
Fig. 1-49.
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Schema of the brachial plexus.
As the nerves of the plexus emerge from between the anterior and middle scalene muscles they become ensheathed with the prevertebral fascia covering the
muscles. This connective tissue investment becomes the axillary sheath which can be injected with anesthetic in surgical procedures of the upper limb.
SURGICAL APPLICATIONS
The brachial plexus in the neck may be palpable in an angle formed between the clavicle and the lower lateral border of the SCM muscle.
The brachial plexus in the neck is related to the following anatomic entities from superficial to deep:
– Anterior
skin
superficial fascia and platysma
branches of supraclavicular nerves
deep fascia (roof of posterior triangle)
external jugular vein and some of its tributaries
omohyoid: posterior belly
transverse cervical artery
nerve to subclavius muscle
third part of subclavian artery in front of the lowest trunk
suprascapular artery
clavicle
– Posterior
middle scalene muscle
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long thoracic nerve
– Inferior
The lowest trunk lies on the first rib, marking it, sandwiched between the subclavian artery in front and the middle scalene behind.
The dorsal scapular artery often (50%) passes between the trunks of the plexus.
Platzer80 categorizes the injuries of the brachial plexus into upper and lower divisions. Injury to the upper plexus can cause Duchenne-Erb paralysis involving
movements of the shoulder joint due to injuries of the roots of C5 and C6 and with secondary involvement of the abductors, lateral rotators of the shoulder joint, and
flexors of the elbow joint and supinator muscle. There may be some disturbance of sensibility at the shoulder and at the radial side of the forearm.
Erb's point (Figs. 1-50, 1-51) is the junction of several nerves. Here the upper trunk of the brachial plexus is formed by the union of the 5th and 6th roots of the
brachial plexus. This very short upper trunk bifurcates forming anterior and posterior divisions. The suprascapular and subclavian nerves are direct branches from the
upper trunk just beyond Erb's point.
Fig. 1-50.
Schema of the formation of the brachial plexus, and its branches in the neck. The twigs to the longus and scalene muscles are not shown.
Fig. 1-51.
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The dotted circle is Erb's point. Meeting are the following nerves: A and B, the fifth and sixth roots of the brachial plexus going to form C, the upper trunk of the
brachial plexus; D and E, anterior and posterior divisions of the upper trunk; F, suprascapular nerve; G, nerve to subclavius muscle.
If the upper trunk at Erb's point is stretched or torn during the birth of a child, Erb's paralysis of the upper arm may result.
Erb's point is located just behind the posterior border of the SCM muscle, approximately 2-3 cm above the clavicle, in the vicinity of the transverse process of the 6th
cervical vertebra.
In a slender person with minimal adipose tissue in the neck, the supraclavicular nerve of the cervical plexus can be palpated.
Isolated injuries of the C7 middle trunk are unusual, but when they occur, adduction and medial rotation of the upper limb are weakened, and extension of the
elbow and metacarpophalangeal joint may be lost. The triceps reflex disappears.
In the lower plexus, trauma to the roots of C8 and T1 may lead to impairment of the long flexors of the fingers, the short muscles of the hand, and loss of
sensibilities at the ulnar side of the hand and forearm (Dejerine-Klumpke paralysis).
THYROID GLAND
EMBRYOGENESIS
Normal Development
The thyroid gland appears by the end of the third week as an epithelial thickening of the floor of the pharynx at the level of the first pharyngeal pouch. This,
the large median thyroid anlage, may be a diverticulum or a solid bud. Cranial growth of the tongue, together with elongation of the embryo, carries the origin
of the thyroid gland far cranial to the gland itself. The site of this origin is the foramen cecum of the adult tongue. In some individuals it is not grossly visible.
The thyroid gland remains connected with the foramen cecum by a minute, solid thyroglossal duct that passes through, or anterior to, the hyoid bone. By the
fifth week of gestation, this duct usually becomes fragmented; persistence of any portion is not unusual. In about 50 percent of the population, the duct can
be traced distally to the pyramidal lobe of the thyroid gland (Fig. 1-52).
Fig. 1-52.
Normal vestiges of thyroid gland development. None are of clinical significance, but their presence may be of concern to the surgeon. (Modified from Skandalakis JE,
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Normal vestiges of thyroid gland development. None are of clinical significance, but their presence may be of concern to the surgeon. (Modified from Skandalakis JE,
Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
The developing gland, at first an irregular plate, develops two lateral wings connected by the isthmus. Follicles appear during the second month of gestation
and increase through the fourth month. Colloid formation and uptake of radioactive iodine begin at about the eleventh week.
Epithelial structures, the paired lateral anlages, are formed from the ventral portions of the fourth and fifth branchial pouches. This structure, the well-known
ultimobranchial body (caudal pharyngeal pouch complex), becomes lost in the developing thyroid gland, and its cells become dispersed as the C (calcitonin)
cells among the thyroid follicles.
Present evidence suggests that the primary origin of the calcitonin-producing cells of the thyroid gland is the neural crest of the embryo. From the neural
crest these cells migrate to the ultimobranchial body,81 and later become part of the thyroid gland. C cells belong to a group of neural-crest derivatives
known as APUD (amine precursor uptake and decarboxylation) cells. Welbourn82 believed that tumors of these cells, medullary carcinomas, account for 6 to 8
percent of all thyroid malignancies. Several other endocrine-producing cells in the gut and tracheal walls, pancreas, and adrenal glands belong to the APUD
system. Tumors of the APUD system are collectively called "apudomas."
Congenital Anomalies
It is not within the scope of this book to present detailed anomalies or variations of the thyroid gland. The student of thyroid anatomy will find complete
coverage in Embryology for Surgeons.83 However, we will mention a few common anomalies and discuss in greater detail the lateral aberrant thyroid.
The anatomy of the abnormal is shown in Table 1-3.
Table 1-3. A Classification of Congenital Anomalies of the Thyroid Glanda
Both Median and Lateral
Anlages
Median Anlage
Lateral Anlage
Neither
Anlage
A. Variable shape and
weight
A. Agenesis
A. Nonfusion with median anlage
A. Vessels
B. Symmetry
1. Isthmus: thick, thin, absent
B. Cysts with squamous epithelial lining
1. Artery
C. Total thyroid agenesis
2. Bilobed partial
C. Solid cell rests: C cells
2. Vein
D. One lobe absent
3. Unilateral
D. Agenesis: Lobdell-DiGeorge syndrome
E. Pyramidal lobe
4. Pyramidal lobe
E. Pharyngeal pouches remnants
1. Absent
5. Short
1. Thymic
2. From the right lobe
6. Long
2. Parathyroid
3. From the left lobe
7. Right or Left
3. Ultimobranchial body
4. From the isthmus
8. Thyroglossal duct
B. Anomalies of descent along the thyroid line
1. Lingual
3. Lymph
B. Muscles
C. Nerves
F. Ectopic thyroid tissue in fat, muscles
G. Fat, muscle cartilage within the thyroid gland
H. Lateral aberrant thyroid not within the capsule of medially located
lymph nodes
2. Sublingual
3. Prelaryngeal
C. Accessory ectopic (i.e., outside the pathway of
descent)
1. Mediastinal
2. Intratracheal
3. Lateral to jugular
4. Ovarian
5. Sella turcica
6. Retrotracheal
7. Preaortic
8. Pericardial
9. Cardiac
10. Porta hepatis
11. Gallbladder
12. Groin
13. Intralaryngeal
14. Intraesophageal
15. Intralymph node
a This
classification is based on the thyroid anlage(s), if any, involving the anomaly.
Source: Skandalakis JE, Gray SW (eds). Embryology for Surgeons, 2nd Ed. Baltimore: Williams & Wilkins, 1994; with permission.
Lingual Thyroid
Occasionally the thyroid gland is not in the normal cervical position, but lies beneath the epithelium of the tongue, at the site of the foramen cecum. LiVolsi84
stated that lingual thyroid (Fig. 1-53) results from a failure of the median anlage to descend from the pharynx.
Fig. 1-53.
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The embryonic path of descent of the thyroid gland. An ectopic thyroid may remain at its level of origin in the tongue, or its descent may be interrupted at any point
along the pathway. Hyperdescent into the thorax (primarily retrosternal thyroid) is also possible. (Modified from Gray SW, Skandalakis JE, Akin JT Jr. Embryological
considerations of thyroid surgery: Developmental anatomy of the thyroid, parathyroid, and the recurrent laryngeal nerve. Am Surg 1976;42:621-628; with
permission.)
The lingual thyroid gland is usually small but normal and is the only thyroid tissue present. Radioactive iodine scintigraphy will aid in the diagnosis and will
determine the presence of other thyroid tissue in the patient.
A thyroid gland may be found anywhere along the track from the foramen cecum to the normal site. Such "partially descended" glands are rare.85
Total excision of a lingual thyroid is necessary. It requires care, because the gland is well vascularized by the lingual arteries. In one series,86 2 out of 12
lingual thyroids were malignant. If no malignancy is reported from frozen sections, the excised tissue can be implanted into the anterior abdominal wall.
Read an Editorial Comment
Persistent Remnants of the Thyroglossal Duct
The foramen cecum of the tongue and the pyramidal lobe of the thyroid gland are normal remnants of the thyroglossal duct. Thyroglossal duct cysts account
for 62.8 percent of all the congenital masses of the neck.87 Of those, according to LiVolsi,88 up to 62 percent contain ectopic thyroid tissue. Primary
carcinoma in thyroglossal duct cyst occurs in less than 1 percent of cases.89,90 Walton and Koch91 presented a case of thyroglossal duct cyst with papillary
carcinoma, and indicated that fewer than 150 cases have been reported. Table 1-4 shows histologic composition and other characteristics of thyroglossal
duct-associated carcinoma in 109 cases. Medullary thyroid cancer has not been reported because there are no C cells in the pyramidal lobe (the parafollicular
C cells arise from the lateral thyroid anlage). Embryology and pathology are in full agreement here.
Table 1-4. Reported Cases of Thyroglossal Duct-Associated Carcinomaa
Histology:
Papillary carcinoma
99
Adenocarcinoma
2
Malignant struma
1
Squamous cells carcinoma
7
Total (reported cases)
109
Female/Male
66:42 (1 unknown)
Age
6 to 81 years
History of neck radiation
a
3
Adapted from LiVolsi VA. Surgical Pathology of the Thyroid. Philadelphia: WB Saunders, 1990.
Source: Skandalakis JE, Gray SW (eds). Embryology for Surgeons, 2nd Ed. Baltimore: Williams & Wilkins, 1994; with permission.
Frequently, individuals who have ectopic thyroid also have an absence of normal thyroid. Therefore, before the ectopic thyroid is excised, it is important to
evaluate whether it is the only thyroid tissue in the body.92
Between the foramen cecum and the pyramidal lobe is a very small epithelial tube, usually broken in several places. Occasionally these epithelial fragments
hypertrophy, secrete fluid, and form cysts. Drainage or aspiration of these cysts is futile and often results in the formation of a fistula, which usually
becomes infected.
All fragments of the duct, foramen cecum, and midportion of the hyoid bone should be removed (Sistrunk procedure). Recurrence of the cyst is the result of
failure to remove the entire duct. Failure to remove the central portion of the hyoid bone resulted in 17 percent recurrence in one series of operations.93 No
nerve, blood vessel, or organ need be injured in this procedure. Quigley et al.94 warned against inadvertent removal of a partially descended thyroid gland
mistaken for a thyroglossal duct cyst.
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Accessory Ectopic Thyroid Tissue
Figure 1-54 demonstrates not only the possible sites of ectopic tissue but also tissues of other anatomic entities within the thyroid parenchyma.
Fig. 1-54.
Left side of drawing illustrates possible sites of accessory ectopic thyroid tissue. Right side of illustration lists other anatomic entities from which tissue may be found
within the thyroid. (Modified from Skandalakis JE, Gray SW. Embryology for Surgeons (2nd ed). Baltimore: Williams & Wilkins, 1994; with permission.)
Bhatnagar et al.95 described an accessory lobe of the thyroid gland located inferior to both lateral lobes and the isthmus. Its arterial supply originated from
the right inferior thyroid artery and its vein drained via the plexus thyroideus impar.
Monchik and Materazzi96 advised that posterior or aberrant mediastinal thyroid masses may require a thoracic surgical approach.
Kumar et al.97 reported an adolescent with dual ectopic thyroid glands located in the sublingual and subhyoid regions, the seventh such case in the
literature.
LATERAL ABERRANT THYROID
Of special interest —and a vexation to surgeon, pathologist, and patient— is lateral aberrant thyroid tissue; that is, tissue located lateral to the jugular
vein.98 It has three morphologic manifestations.
This tissue may be found as a nodule attached by connective tissue to the mother gland. These thyroid tissue "islands," which pull away from the visceral
body during development, are nevertheless normal.
The second site for lateral thyroid tissue is within lymph nodes or their remnants. We should consider a cervical lymph node containing thyroid follicles to be
clinically a metastatic thyroid carcinoma. However, the existence of heterotopic thyroid tissue within cervical glands has been reported. Six such cases of
normal thyroid gland at 5-Ìm sections were described by Sawicki et al.99
The final morphologic expression of laterally aberrant thyroid tissue must be termed congenital. Rubenfeld et al.100 reported a patient whose only thyroid
tissue, by all appearances, was lateral aberrant thyroid tissue.
Always consider the possibility of metastatic thyroid cancer of lateral aberrant thyroid nodules.
STRUMA OVARII
Struma ovarii, the ovarian thyroid, is an extraordinary thyroid ectopia, although it is unrelated to the anatomic thyroid gland and is not a true congenital
anomaly. Ovarian thyroid tissue is a fellow traveller with dermoid cysts and teratoma. According to estimates of Woodruff et al.,101 struma ovarii may exist in
0.2-1.3% of all ovarian tumors. Of these, 5-6% are bilateral and about 5% possess functioning thyroid tissue. Kempers et al.102 found hyperthyroidism in
struma ovarii. Malignancy is a possible occurrence in as many as 5% of all struma ovarii,103 with metastasis noted in papillary carcinoma.98,104
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SURGICAL ANATOMY
General Topography
The thyroid gland consists typically of two lobes, a connecting isthmus, and an ascending pyramidal lobe. One lobe, usually the right, may be smaller than the
other (7 percent) or may even be completely absent (1.7 percent). The isthmus is absent in about 10 percent of thyroid glands, and the pyramidal lobe is
absent in about 50 percent (see Fig. 1-52). A minute epithelial tube or fibrous cord, the thyroglossal duct, almost always extends between the thyroid gland
and the foramen cecum of the tongue.
The thyroid gland normally extends from the level of the 5th cervical vertebra to the body of the 1st thoracic vertebra. It may lie higher (lingual thyroid), but
rarely lower.105
The normal thyroid gland weighs about 30 g in the adult —somewhat more in females than in males. Each lobe is approximately 5 cm in length, 3 cm at its
greatest width, and 2-3 cm thick.106 The isthmus connecting the two lobes is about 1.3 cm in breadth. The lobes have a broad lower portion and a relatively
conical apex.
Capsule of the Thyroid Gland
Like many other organs, the thyroid gland has a connective tissue capsule which is continuous with the septa, and which makes up the stroma of the organ.
This is the true capsule of the thyroid.
External to the true capsule is a well developed (to a lesser or greater degree) layer of fascia derived from the pretracheal fascia. This is the false capsule,
also called the perithyroid sheath or surgical capsule. Anteriorly and laterally this fascia is well developed; posteriorly it is thin and loose, permitting
enlargement of the thyroid gland posteriorly. There is a thickening of the fascia that fixes the back of each lobe to the cricoid cartilage. Such thickenings are
the ligaments of Berry. The false capsule, or fascia, is not removed with the gland during thyroidectomy.
The superior parathyroid glands normally lie between the true capsule of the thyroid and the fascial false capsule. The inferior parathyroids may be between
the true and false capsules, within the thyroid parenchyma, or lying on the outer surface of the fascia. The levator muscle of the thyroid is one or more
muscular slips that occasionally connect the hyoid bone with the thyroid gland. These vestigial muscles are inconstant in occurrence, location, and
innervation. They have been divided into anterior, lateral, and posterior levators.
Vascular Supply
The thyroid gland competes with the adrenal glands for having the greatest blood supply per gram of tissue.107 One consequence is that hemostasis is a
major problem of thyroid surgery, especially in patients with toxic goiter.
Arteries
Two paired arteries, the superior and inferior thyroid arteries, and an inconstant midline vessel, the thyroid ima artery, supply the thyroid (Fig. 1-55).
Fig. 1-55.
The arterial supply to the thyroid gland. The thyroid ima artery is only occasionally present. (Modified from Tzinas S, Droulias C, Harlaftis N, Akin JT Jr, Gray SW,
Skandalakis JE. Vascular patterns of the thyroid gland. Am Surg 1976;42:639-644; with permission.)
SUPERIOR THYROID ARTERY
The superior thyroid artery arises from the external carotid artery just above, at, or just below the bifurcation of the common carotid artery. It passes
downward and anteriorly to reach the superior pole of the thyroid gland. In part of its course, the artery parallels the external branch of the superior
laryngeal nerve which supplies the cricothyroid muscle and the cricopharyngeus muscle, the lowest voluntary part of the pharyngeal musculature.
There are six branches of the superior thyroid artery (Fig. 1-56): the infrahyoid, sternocleidomastoid, superior laryngeal, cricothyroid, inferior pharyngeal
constrictor, and terminal branches of the artery for the blood supply of the thyroid and parathyroid glands. Usually there are two branches to the thyroid —
the anterior and posterior— but occasionally there may be a third, the so-called lateral branch (Fig. 1-56).
Fig. 1-56.
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Branches of the superior thyroid artery. (Modified from Montgomery RL. Head and Neck Anatomy: With Clinical Correlations. New York: McGraw-Hill, 1981; with
permission.)
At the superior pole, the superior thyroid artery divides into anterior and posterior branches. The anterior branch anastomoses with the contralateral
artery;108 the posterior branch anastomoses with branches of the inferior thyroid artery. From the posterior branch, a small parathyroid artery passes to the
superior parathyroid gland.
In a study of thyroid glands removed at autopsy from Japanese patients, Nobori et al.109 observed that an anastomosing vessel from the posterior branch of
the superior thyroid artery supplied the superior parathyroid in 45% of cases. The majority of 92 glands (67%) had a single artery of supply; 1/3 had two or
more small vessels which entered the gland. In the photographs of the specimens, the branching pattern of the primary vessel supplying the gland appeared
to indicate that its origin was from the superior thyroid artery.
Weiglein110 reported a rare variation of blood supply to the thyroid gland. In this case, the right inferior thyroid artery was replaced by an artery originating
from the right internal thoracic artery. The left inferior thyroid artery was replaced by an artery arising from the vertebral artery.
INFERIOR THYROID ARTERY
The inferior thyroid artery usually arises from the thyrocervical trunk, but in about 15 percent of individuals it arises directly from the subclavian artery.111
The inferior thyroid artery ascends behind the carotid artery and the internal jugular vein, passing medially and posteriorly on the anterior surface of the
longus coli muscle. After piercing the prevertebral fascia, the artery divides into two or more branches as it crosses the ascending recurrent laryngeal nerve.
The recurrent laryngeal nerve may pass anterior or posterior to the artery, or between its branches (Fig. 1-57). The lowest branch sends a twig to the
inferior parathyroid gland and supplies the lower pole of the thyroid gland. The upper branch supplies the posterior surface of the gland, usually anastomosing
with a descending branch of the superior thyroid artery. On the right, the inferior thyroid artery is absent in about 2 percent of individuals. On the left, it is
absent in about 5 percent (Hunt et al.).112 The artery is occasionally double.113
Fig. 1-57.
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Relations at the crossing of the recurrent laryngeal nerve and the inferior thyroid artery. A-C, Common variations. Their frequencies are given in Table 1-9. D, A
nonrecurrent nerve is not related to the inferior thyroid artery. E, The nerve loops beneath the artery. (Modified from Tzinas S, Droulias C, Harlaftis N, Akin JT Jr, Gray
SW, Skandalakis JE. Vascular patterns of the thyroid gland. Am Surg 1976;42:639-644; with permission.)
THYROID IMA ARTERY
The thyroid ima artery is unpaired and inconstant. It arises from the brachiocephalic artery, the right common carotid artery, or the aortic arch. It occurs in
about 10 percent of individuals, according to Montgomery.41 It may be as large as an inferior thyroid artery or it may be a mere twig. Its position anterior to
the trachea makes it important in tracheostomy.
Veins
Veins of the thyroid gland form a plexus of vessels lying in the substance and on the surface of the gland. The plexus is drained by three pairs of veins, the
superior, middle, and inferior thyroid veins (Fig. 1-58).
Fig. 1-58.
The venous drainage of the thyroid gland. The inferior thyroid veins are quite variable. (Modified from Tzinas S, Droulias C, Harlaftis N, Akin JT Jr, Gray SW,
Skandalakis JE. Vascular patterns of the thyroid gland. Am Surg 1976;42:639-644; with permission.)
SUPERIOR THYROID VEIN
The superior thyroid vein accompanies the superior thyroid artery. Emerging from the superior pole of the thyroid, the vein passes superiorly and laterally
across the omohyoid muscle and the common carotid artery to enter the internal jugular vein alone or with the common facial vein.
MIDDLE THYROID VEIN
The middle thyroid vein arises on the lateral surface of the gland at about two-thirds of its anteroposterior extent. No artery accompanies it. It crosses the
common carotid artery to open into the internal jugular vein. This vein may be absent or, occasionally, double. The extra vein is inferior to the normal one; it
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common carotid artery to open into the internal jugular vein. This vein may be absent or, occasionally, double. The extra vein is inferior to the normal one; it
has been called the "fourth" thyroid vein. The importance of these middle thyroid veins is in their vulnerability during thyroidectomy.
INFERIOR THYROID VEIN
The inferior thyroid vein is the largest and most variable of the thyroid veins; the right and left sides are usually asymmetric. The right vein leaves the lower
border of the thyroid gland, passes anterior to the brachiocephalic artery, and enters the right brachiocephalic vein. The left vein crosses the trachea to
enter the left brachiocephalic vein. Rarely, the right vein crosses the trachea to enter the left brachiocephalic vein, sometimes forming a common trunk with
the left vein. This common trunk is called the thyroid ima vein.
Lymphatics
Several broad patterns of lymphatic drainage of the thyroid gland have been proposed (Fig. 1-59). Each conceptualization is based on the same facts; each
is correct. We will follow that of Hollinshead36 (Fig. 1-59C). The actual drainage is shown in Fig. 1-60.
Fig. 1-59.
Three concepts of the lymphatic drainage of the thyroid gland. A, Edis et al.352 B, McGregor and DuPlessis.76 C, Hollinshead.36 All three concepts are correct and
based on the same facts. (Modified from Tzinas S, Droulias C, Harlaftis N, Akin JT Jr, Gray SW, Skandalakis JE. Vascular patterns of the thyroid gland. Am Surg
1976;42:639-644; with permission.)
Fig. 1-60.
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The lymph nodes receiving drainage from the thyroid gland. After the description of Rouviere.359 (Modified from Tzinas S, Droulias C, Harlaftis N, Akin JT Jr, Gray SW,
Skandalakis JE. Vascular patterns of the thyroid gland. Am Surg 1976;42:639-644; with permission.)
PATTERNS OF DRAINAGE
Median Superior Drainage
Three to six vessels arise from the superior margin of the isthmus and from the medial margins of the lateral lobes. These vessels pass upward in front of the
larynx to end in the digastric lymph nodes. Some vessels may enter one or more prelaryngeal ("Delphian") nodes just above the isthmus. Secondary drainage
may be to upper jugular nodes on either side or to pretracheal nodes below the thyroid by a vessel passing from the Delphian nodes downward over the front
of the thyroid.
It has been suggested that there is a connection between the lymphatic drainage of the superior thyroid artery and the orbit by way of the jugular chain of
cervical lymph nodes.114 In neither the orbit nor the eye itself can lymphatic vessels be demonstrated.115 The immediate cause of exophthalmus associated
with thyroid disease is the enlargement of the extraocular muscles, especially the inferior rectus and inferior oblique. Thyroid antigen or antigen-antibody
complexes reaching the eye from the thyroid gland produce an autoimmune response in the extraocular muscles.
Median Inferior Drainage
Several lymph vessels drain the lower part of the isthmus and the lower medial portions of the lateral lobes. They follow the inferior thyroid veins to end in
the pretracheal and brachiocephalic nodes.
Right and Left Lateral Drainage
Lymphatic trunks arise from the lateral border of each lobe. Superiorly they pass upward with the superior thyroid artery and vein. Inferiorly they follow the
inferior thyroid artery. Between these two groups, some vessels pass laterally, anteriorly, or posteriorly to the carotid sheath to reach the lymph nodes of
the internal jugular chain. Occasionally, such vessels drain into the right subclavian vein, jugular vein, or thoracic duct without passing through a lymph
node.116
Posterior Drainage
Posterior lymphatic vessels arise from the inferomedial surfaces of the lateral lobes to drain into nodes along the recurrent laryngeal nerve. Occasionally, a
posterior ascending trunk from the upper part of the lobe reaches the retropharyngeal nodes.
METASTATIC SPREAD
A representation of lymph node regions of importance for management of thyroid carcinoma is seen in Fig. 1-61. Lymph node groups at the highest risk for
regional metastasis from differentiated thyroid carcinoma are shown in Fig. 1-62.
Fig. 1-61.
Lymph node regions of importance for management of thyroid carcinoma. (Modified from Callender DL, Sherman SI, Gagel RF, Burgess MA, Goepfert H. Cancer of the
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Lymph node regions of importance for management of thyroid carcinoma. (Modified from Callender DL, Sherman SI, Gagel RF, Burgess MA, Goepfert H. Cancer of the
thyroid. In: Myers EN, Suen JY (eds). Cancer of the Head and Neck (3rd ed). Philadelphia: WB Saunders, 1996, p. 485-515; with permission.)
Fig. 1-62.
Diagram illustrating lymph node groups at highest risk for regional metastasis from differentiated thyroid carcinoma. (Modified from Goepfert H, Callender DL.
Differentiated thyroid cancer – papillary and follicular carcinoma. Am J Otolaryngol 1994;15:167-179; with permission.)
A study by Gemsenjäger et al.117 of patients with differentiated thyroid carcinoma concluded that papillary carcinoma pT1-3 N0 M0 and minimally invasive
follicular carcinoma without nodal or distant metastasis can be adequately treated with hemithyroidectomy or total thyroidectomy only and without
radioiodine, while all the other tumors such as invasive follicular cancer were treated adequately with total bilateral lobectomy and radioiodine.
Feind118 found metastatic involvement of middle jugular lymph nodes in 85 of 111 specimens from patients with thyroid carcinoma. In 67 of these, lower
jugular nodes were positive. Submandibular and mediastinal nodes were rarely affected.
Table 1-5, based on more than 1,000 patients of Shaha et al.,119 summarizes the incidence of nodal metastasis and distant metastasis in differentiated
thyroid carcinoma. Shaha et al. concluded that the risk of nodal and distant metastasis varies considerably based on individual histologic variety.
Table 1-5. Incidence of Metastasis in Thyroid Carcinoma
Nodal Metastasis
Distant Metastasis
Papillary
61%
10%
Follicular
30%
22%
Hurthle cell
21%
33%
Source: Data from Shaha AR, Shah JP, Loree TR. Patterns of nodal and distant metastasis based on histologic varieties in differentiated carcinoma of the thyroid. Am J
Surg 172:692-694, 1996.
Read an Editorial Comment
Innervation
The thyroid gland is innervated by the sympathetic system from the superior, middle, and inferior ganglia of the cervical chain. But in thyroid surgery the
recurrent and superior laryngeal nerves of the parasympathetic (vagus) system (which play no role in the innervation of the gland) are of utmost importance,
so we consider them here.
Recurrent Laryngeal Nerves (Inferior Laryngeal)
NORMAL ANATOMY
The right and left recurrent laryngeal nerves are intimately related to the thyroid gland. The right recurrent nerve branches from the vagus as it crosses
anterior to the right subclavian artery. The right recurrent nerve (Fig. 1-63B) loops around the subclavian artery from posterior to anterior, crosses behind
the right common carotid and ascends in or near the tracheoesophageal groove. It passes posterior to the right lobe of the thyroid gland to enter the larynx
behind the cricothyroid articulation and the inferior cornu of the thyroid cartilage.
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Fig. 1-63.
The embryonic aortic arches and the "recurrence" of the laryngeal nerve. A, Normal embryo with third, fourth, and sixth aortic arches present. The laryngeal nerve
arises from the vagus nerve and passes under and behind the sixth aortic arch. B, Normal adult. On the right, the laryngeal nerve passes under the subclavian
artery; on the left, it passes under the ligamentum arteriosum. C, In the presence of a retroesophageal right subclavian artery, the nerve passes to the larynx
without "recurring." D, In the presence of a right aortic arch, the right nerve loops under the arch; the left nerve passes directly to the larynx. C and D are
encountered in less than 1 percent of specimens. (Modified from Skandalakis JE, Droulias C, Harlaftis N, Tzinas S, Gray SW, Akin JT Jr. Recurrent laryngeal nerves. Am
Surg 1976;42:629-634; with permission.)
The left recurrent nerve arises where the vagus nerve crosses the aortic arch, just distal to the origin of the left subclavian artery from the aortic arch. It
loops under the ligamentum arteriosum and the aorta, and ascends in the same manner as the right nerve. Both nerves cross the inferior thyroid arteries near
the lower border of the middle third of the gland.
VARIATIONS
Several variations may occur in the courses of the recurrent nerves. All serve to increase the possibility of injury to the nerve during thyroid surgery.
Katz and Nemiroff 120 visualized 1,117 recurrent laryngeal nerves. They reported that 747 (63%) bifurcated or trifurcated more than 0.5 cm from the cricoid
cartilage. Bilateral nerve bifurcation was observed in 170 patients.
In an earlier version of this research, these authors wisely concluded that "extralaryngeal branches of the recurrent laryngeal nerve are not an anatomic
rarity. Therefore, thyroid surgery must include identification and preservation of the recurrent laryngeal nerve and all of its divisions."121
In about 1 percent of patients, the right recurrent nerve arises normally from the vagus, but passes medially almost directly from its origin to the larynx
without looping under the subclavian artery (Fig. 1-63C). In these cases, the right subclavian artery arises from the descending aorta and passes to the right
behind the esophagus. This anomaly is asymptomatic, and the thyroid surgeon will rarely be aware of it prior to operation. Even less common is a
nonrecurrent left nerve in the presence of a right aortic arch and a retroesophageal left subclavian artery (Fig. 1-63D).
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In the lower third of its course, the recurrent laryngeal nerve ascends behind the pretracheal fascia at a slight angle to the tracheoesophageal groove. In the
middle third of its course, the nerve may lie in the groove, medial to the suspensory ligament of the thyroid gland (ligament of Berry), within the ligament, or
within the substance of the thyroid gland.
Skandalakis et al.122 examined the course of the recurrent laryngeal nerve in 102 cadavers (204 sides). In about half of the specimens, the nerve lay in the
tracheoesophageal groove. In the other half, most were anterior to the groove (paratracheal); a few lay posterior (paraesophageal). In 8 of the 204 sides,
the nerve lay within the gland (Fig. 1-64). Other workers have found a slightly higher percentage of intraglandular nerves.123
Fig. 1-64.
The course of the recurrent laryngeal nerve at the thyroid gland in 102 cadavers. About half the nerves were found in the groove between the trachea and the
esophagus. A, Lateral view. B, Cross-sectional view. (Modified from Skandalakis JE, Droulias C, Harlaftis N, Tzinas S, Gray SW, Akin JT Jr. Recurrent laryngeal nerves.
Am Surg 1976;42:629-634; with permission.)
Read an Editorial Comment
The senior author of this chapter (JES) feels very strongly that the "recurrent laryngeal nerve" should be named or renamed the inferior laryngeal nerve.
We quote from Schweizer and Dörfl124:
[I]t is particularly interesting for laryngeal surgeons to notice the minor variability of branching of the inferior laryngeal nerve and of its mode of
entrance into the hypopharynx. Even in the case of a unilateral single trunk, the nerve passes just behind the cricothyroid joint and can be easily
identified. Variations...were mainly limited to the level of the extralaryngeal division of the inferior laryngeal nerve. Thus, the surgeon can rely on
precise and consistent landmarks in this part of the body, as in other anatomical locations.
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precise and consistent landmarks in this part of the body, as in other anatomical locations.
The recurrent laryngeal nerve is safest and least visible when it lies in the tracheoesophageal groove. It is most vulnerable when it traverses the thyroid
parenchyma. Where it runs in the suspensory ligament of the thyroid, it must be identified and protected before the ligament is divided.
The recurrent laryngeal nerve crosses the inferior thyroid artery at the middle third of the gland. It may lie anterior or posterior to, or between the branches
of the artery.125 Lekacos et al.126 reported that most recurrent laryngeal nerves (approximately 80%) are located either posterior to or between the
branches of the inferior thyroid artery. The three major types of crossings were shown previously in Fig. 1-57A-C. A series by Skandalakis et al.122 showed
that the right nerve most frequently lay between arterial branches (48 percent); the left nerve was usually behind the artery (64 percent). Table 1-6 shows
the relative incidence of the types of crossing. No one pattern can be considered "normal"; the surgeon must be prepared for any configuration of artery and
nerve.
Table 1-6. Relationship of Recurrent Laryngeal Nerve and Inferior Thyroid Artery
Per Cent Frequency
102 Cadavers
1246 Cases From Literature
Relation
Right Left
Both Sides Both Sides
Nerve anterior to artery
31.4
9.8
20.6
21.1
Nerve posterior to artery
19.6
63.7
41.6
50.4
Nerve between branches of artery 48.0
26.5
37.3
24.8
Nonrecurrent nerve and other
–
0.5
3.6
1.0
100.0 100.0 100.0
100.0
Source: Skandalakis JE, Droulias C, Harlaftis N, Tzinas S, Gray SW, Akin JT Jr. The recurrent laryngeal nerve. Am Surg 42(9):629-634, 1976; with permission.
Kreyer and Pomaroli127 reported an anastomosis between the external branch of the superior laryngeal nerve and the recurrent laryngeal nerve.
Sturniolo et al.128 emphasized that the secret to avoiding injury to the recurrent laryngeal nerve during thyroid surgery is as follows: (1) deep knowledge of
the surgical anatomy of the thyroid region; (2) total extracapsular thyroidectomy; (3) a thorough search, identification, and exposure of the nerve itself; and
(4) following the course of the nerve with care.
According to Procacciante and colleagues,129 after the recurrent laryngeal nerve is made taut by upward and medial traction of the thyroid, it may be
palpated caudally to the inferior pole of the gland. This maneuver aided safe dissection in the region of the inferior thyroid artery.
Marchesi et al.130 reported an occurrence rate of 0.34% for a nonrecurrent inferior laryngeal nerve on the right side, and extreme rarity on the left side.
They report seven cases of nonrecurrent laryngeal nerve, and emphasize the diagnostic accuracy of angio-MR for the anatomic identification of the vascular
anomaly that invariably occurs with the nerve malformation.
The nonrecurrent nerve (left or right, when present) may pass directly to the larynx with no relation to the inferior thyroid artery (Fig. 1-57D), or such a
nerve may loop around the artery (Fig. 1-57E).
Avisse et al.131 reported 17 cases of a right nonrecurrent inferior laryngeal nerve. In two of these cases an aberrant right subclavian artery coexisted with a
nonrecurrent inferior laryngeal nerve.
Sanders et al.,132 who found seven cases of nonrecurrent laryngeal nerves in 1,000 thyroidectomies, reported the following:
In two of these seven cases, both a nonrecurrent nerve and an additional recurrent branch were present on the right side. This double nerve
presentation has not been described before. Unless one is aware of this possibility, one might inadvertently injure the major nonrecurrent trunk, having
identified only a small recurrent branch. We emphasize the need for a complete nerve identification technique.
Miyauchi et al.133 reported good results with simple neurorrhaphy or with graft (vagus nerve - ansa cervicalis) of the injured recurrent nerve. Their 8 patients
recovered from hoarseness, and maximum phonation improved. Steinberg et al.134 stated that branches of the recurrent laryngeal nerve (motor as well as
sensory), together with sympathetic nerves, supply the larynx beneath the cords, pharynx, cervical esophagus, and cervical trachea.
EXPOSURE
Exposure of the recurrent nerve during any procedure on the thyroid is a sound surgical principle and should be done wherever possible. If the nerve cannot
be found readily, the surgeon must avoid the areas in which it may be hidden. Fibrosis, increased bleeding, and lack of clear anatomic relationships are
responsible for most nerve injuries. Postoperative exploration for hemorrhage also is associated with a higher risk of nerve injury.135
At one time the recurrent nerve was considered so delicate that "if a recurrent laryngeal nerve is seen during thyroidectomy, it is injured."136 At the other
extreme are those who would require demonstration of the nerve by direct stimulation during laryngoscopic observation of the vocal cords.137 We believe
that visual identification, with avoidance of traction, compression, or stripping the connective tissue is all that is necessary. Complete anatomic dissection is
not required, but simple exposure will not destroy it. From their investigation of 803 goiter operations and a literature search, Jatzko et al.138 noted a
significantly higher rate of injury to the recurrent laryngeal nerve when it was not identified (5.2%) than when it was exposed (1.2%).
The recurrent laryngeal nerve forms the medial border of a triangle bounded superiorly by the inferior thyroid artery and laterally by the common carotid
artery. The nerve can be identified where it enters the larynx just posterior to the inferior cornu of the thyroid cartilage.139 If the nerve is not found, a
nonrecurrent nerve should be suspected, especially on the right.
Pelizzo et al.140 advised that the best way to locate the recurrent laryngeal nerve during thyroidectomy is the Zuckerkandl's tuberculum, which is located on
the lateral portion of each of the thyroid lobes, and according to these authors is the constant anatomic landmark when present (Fig. 1-65)
Fig. 1-65.
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Fig. 1-65.
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Zuckerkandl's tuberculum size. 0, unrecognizable; 1, only a thickening of the lateral edge of the thyroid lobe; 2, smaller than 1 cm; 3, larger than 1 cm. (Modified
from Pelizzo MR, Toniato A, Gemo G. Zuckerkandl's tuberculum: an arrow pointing to the recurrent laryngeal nerve (constant anatomical landmark). J Am Coll Surg
1998;187:333-336, 1998; with permission.)
The tubercle of Zuckerkandl is the most posterior extension of the lateral lobes of the thyroid gland at the level of the ligament of Berry141,142 (Fig. 1-66).
Fig. 1-66.
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The region of the tubercle of Zuckerkandl (the most posterior extent of the thyroid lobe) and the distal course of the recurrent laryngeal nerve (RLN). The relation of
the RLN to the remaining remnant of thyroid and mechanism for possible RLN injury are shown. (Modified from Thompson NW. Thyroid gland. In: Greenfield LJ (ed).
Surgery: Scientific Principles and Practice (2nd ed). Philadelphia: Lippincott-Raven, 1997, pp. 1283-1308; with permission.)
To digress for a moment, I (JES), the senior author of this chapter, would like to point out that never in my 50 years in the anatomy lab and operating room
did I notice the tubercle of Zuckerkandl. To my embarrassment and frustration, I had not heard of this specific protuberance of the thyroid lobe until I read
the previously mentioned excellent publication by Pelizzo et al.140
In the lower portion of the course of the recurrent laryngeal nerve, the nerve can be palpated as a tight strand over the tracheal surface. There is more
connective tissue between the nerve and the trachea on the right than on the left.
Superior Laryngeal Nerve
The superior laryngeal nerve arises from the vagus nerve just inferior to its lower sensory ganglion just outside the jugular foramen of the skull. The nerve
passes inferiorly, medial to the carotid artery. At the level of the superior cornu of the hyoid bone it divides into a large, sensory, internal laryngeal branch
and a smaller, motor, external laryngeal branch, serving the cricothyroid muscle143 and the cricopharyngeus. The point of division is usually within the
bifurcation of the common carotid artery (Fig. 1-67).
Fig. 1-67.
Branching of the superior laryngeal nerve and the carotid arteries. A, The internal branch crosses the external carotid artery above the origin of the lingual artery. B,
The internal branch crosses below the origin of the lingual artery. C, The nerve divides medial to the external carotid artery. (Modified from Droulias C, Tzinas S,
Harlaftis N, Akin JT Jr, Gray SW, Skandalakis JE. The superior laryngeal nerve. Am Surg 1976;42:635-638; with permission.)
Sun and Dong144 dissected 60 adult cadavers (120 superior laryngeal nerves) and reported the morphology and topography of the superior laryngeal nerve,
its branches, its anastomoses with the cervical sympathetic, and its relations to the thyroid gland. An anastomotic loop connecting the cervical sympathetic
chain and the distal laryngeal nerve was present in 111 of the 120 cases. The morphology of this loop made it possible to define five different types. Figures
1-68 and 1-69 are from their interesting paper, and we urge all surgeons who perform thyroid surgery to read it.
Fig. 1-68.
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The sketch of the coronal section of the larynx shows the superior laryngeal nerve trunk(s) in the environment of the sternothyroid-laryngeal triangle, which is
bounded laterally by the sternothyroid muscle, medially by the inferior pharyngeal constrictor and cricothyroid muscles, and inferiorly by the superior pole of the
thyroid gland. a, single nerve trunk, 89 sides (74.2%); b, single nerve trunk, 1 side (0.8%); c, double nerve trunks, 24 sides (20%); d, double nerve trunks, 4 sides
(3.3%); e, triple nerve trunks, 1 side (0.8%); f, quadruple nerve trunks, 1 side (0.8%). (Modified from Sun SQ, Dong JP. An applied anatomical study of the superior
laryngeal nerve loop. Surg Radiol Anat 1997;19:169-173; with permission.)
Fig. 1-69.
Variations of laryngeal nerves. Type I, V-shaped in 94 sides (78.3 ± 3.8%). Type II, U-shaped in 8 sides (6.7 ± 2.3%). Type III, Mixed in 14 sides (11.7 ± 2.9%).
Type IV, Juxtaposed-double in 1 side (0.8 ± 0.8%). Type V, Juxtaposed-triple in 1 side (0.8 ± 0.8%). SLN, superior laryngeal nerve; ILN, internal laryngeal nerve;
SCG, superior cervical ganglion; CT, communicating twig; ELN, external branch of laryngeal nerve; CTB, cricothyroid muscle branch; GB, thyroid branch. (Modified from
Sun SQ, Dong JP. An applied anatomical study of the superior laryngeal nerve loop. Surg Radiol Anat 1997;19:169-173; with permission.)
To prevent iatrogenic injury of the superior laryngeal nerve during surgical dissection near the thyroid apex in the neck, el-Guindy and Abdel-Aziz145
recommended anatomical localization of the nerve in the viscerovertebral angle, functional identification, and post-operative analysis.
INTERNAL LARYNGEAL NERVE
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INTERNAL LARYNGEAL NERVE
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The internal laryngeal branch pierces the thyrohyoid membrane with the superior laryngeal branch of the superior thyroid artery to enter and supply the
larynx. The internal branch is rarely identified by the surgeon; identification occurs only in those cases where a greatly enlarged upper pole of the thyroid
gland rises above the superior border of the thyroid cartilage (Fig. 1-70). The internal laryngeal nerve provides general sensory fibers to the larynx and the
area of the piriform recess of the laryngopharynx. It also provides parasympathetic fibers for the glandular elements and some taste fibers that supply taste
buds around the epiglottis.
Fig. 1-70.
Relationship between the (A) internal and (B) external branches of the superior laryngeal nerve with the superior thyroid artery and the upper pole of the thyroid
gland. (Modified from Droulias C, Tzinas S, Harlaftis N, Akin JT Jr, Gray SW, Skandalakis JE. The superior laryngeal nerve. Am Surg 1976;42:635-638; with permission.)
EXTERNAL LARYNGEAL NERVE
The external laryngeal branch, together with the superior thyroid vein and artery, passes under the sternothyroid muscles, posterior and medial to the
vessels. The nerve then passes beneath the lower border of the thyrohyoid muscle to continue inferiorly to innervate the cricothyroid muscle. In addition to
its contribution to phonation, the cricothyroid muscle plays a major role in the overall regulation of breathing by its control of expiratory resistance and
flow.146
An investigation by Wu et al.147 suggested that in some individuals a branch of the external laryngeal nerve may also contribute to the innervation of the
thyroarytenoid muscle and to the sensory supply of the vocal fold of the larynx. They postulated that the communicating branch of this nerve might
represent the nerve of the 5th embryonic branchial arch.
Cernea et al.148 stated that injury to the external branch of the superior laryngeal nerve will most likely endure, causing a permanent voice change for
professional vocalists. Fatigue, also, is common after injury to the external branch of the superior laryngeal nerve. Cernea et al. advised nerve identification
in the operating room, especially for patients with large goiters. The topographic anatomy and relations of the nerves and thyroid vessels are presented in
Figure 1-71. Cernea and colleagues have also presented further findings about the surgical anatomy of the superior laryngeal nerve.149,150
Fig. 1-71.
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Classification of the external branch of the superior laryngeal nerve, according to the potential risk of iatrogenic lesion during a hypothetical thyroidectomy. Type 1,
The nerve crosses the superior thyroid vessels 1 or more centimeters above a horizontal plane passing the upper border of the superior thyroid pole. Type 2a,
Nerve crossing the vessels less than 1 cm above the plane. Type 2b, Nerve crossing the vessel below the plane. (Modified from Cernea CR, Nishio S, Hojaij FC.
Identification of the external branch of the superior laryngeal nerve (EBSLN) in large goiters. Am J Otolaryngol 1995;16:307; with permission.)
In most patients, the blood vessels lie within the visceral compartment of the neck beneath the pretracheal fascia, while the external laryngeal nerve lies
between the fascia and the inferior pharyngeal constrictor muscle. There is thus a plane of dissection between the vessels and the nerve. In about 25
percent of individuals, the nerve lies beneath the fascia together with the vessels.151
HISTOLOGY
The thyroid gland is surrounded by the thyroid capsule, which is a thin layer of connective tissue. From the capsule, several septa extend within the thyroid
parenchyma, which is subdivided into several lobules. Epithelial cells (cuboidal or squamous) form the thyroid follicles; they are separated by thin connective
stroma which is rich in both lymphatic and blood vessels. Small bundles of nerves are present.
There is a colloidal gelatinous collection in the center of the follicle. Each follicle has two types of cells: follicular and parafollicular, or C cells.
According to Ross and Reith,152 the follicular cells are responsible for the following actions: synthesis of thyroglobulin, iodination, storage of thyroglobulin,
resorption of thyroglobulin, hydrolysis of thyroglobulin, and release of thyroid hormone into the blood and lymphatics.
The parafollicular, or C cells, can be found in the connective stroma between the follicles or in the follicular epithelium. Characteristically, they contain
several secretory granules.
PHYSIOLOGY
The follicular cells of the thyroid gland produce the thyroid hormones thyroxine (T 4) and triiodothyronine (T 3). The follicular cells trap and concentrate iodide
from that serum. The final product, thyroglobulin, accumulates within the colloid.
Figures 1-72 and 1-73 illustrate the synthesis of the hormones of the thyroid gland and their regulated secretion. Another function of the thyroid gland is the
secretion of thyrocalcitonin, which is the product of the parafollicular or C cells.
Fig. 1-72.
The synthesis and secretion of thyroxine (T4 ) and triiodothyronine (T3 ). TSH, thyroid-stimulating hormone; MIT, monoiodotyrosine; DIT, diiodotyrosine. (From Polk HC
Jr, Gardner B, Stone HH. Basic Surgery (5th ed). St. Louis: Quality Medical, 1995; with permission.)
Fig. 1-73.
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The physiologic regulation of thyroid hormone secretion and the thyroid tests which measure these parameters. TRH, thyrotropin-releasing hormone; TSH, thyroidstimulating hormone; TSI, thyroid-stimulating immunoglobulins; LATS, long-acting thyroid stimulator; TBG, thyroxine-binding globulin; FTI, free thyroxine index.
(Modified from Polk HC Jr, Gardner B, Stone HH. Basic Surgery (5th ed). St. Louis: Quality Medical, 1995; with permission.)
THYROID SURGERY
The surgical procedures for thyroid pathology are total bilateral lobectomy, total unilateral with partial contralateral lobectomy, and partial or subtotal
lobectomy (unilateral or bilateral). There is much controversy as to which is the most appropriate choice for each patient and each disease. The surgical
profession agrees to disagree about all these procedures.
Recently, minimally invasive thyroid surgery has been performed successfully. Ferzli et al.153 reported feasible and safe mini-thyroidectomy on glands no
larger than 7 cm.
We agree with the advice of Bliss and colleagues,154 "Minimally invasive thyroidectomy utilizing endoscopic techniques may also affect the practice of thyroid
surgery. Even so, understanding the surgical anatomy of the thyroid gland and its possible variations is paramount to safe and effective surgery."
We present the valuable flowchart of Johns155 for management of solitary thyroid nodules (Fig. 1-74). Delbridge et al.156 reported that the procedure of
choice for bilateral benign multinodular goiter is total thyroidectomy, since that procedure obviates recurrent goiter and a need for secondary thyroidectomy.
Fig. 1-74.
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Management flowchart for patient with solitary thyroid nodule. TSH, thyroid-stimulating hormone; FNA, fine-needle aspiration; RAD, radiation absorbed dose.
(Modified from Johns ME. The solitary thyroid nodule. Curr Ther Otolaryngol 1987;3:226-229; with permission.)
Read an Editorial Comment
Another surgical dilemma is the treatment of hyperparathyroidism, which is considered in the following section on the parathyroid gland.
According to Cooper,157 treatment of hyperthyroidism is still somewhat controversial. American endocrinologists advise antithyroid drugs for young individuals,
but iodine 131 for adults. European and Japanese endocrinologists are more likely to recommend antithyroid drugs regardless of the patient's age. All over the
world, surgery is used infrequently.
Ron et al.158 reported that iodine 131 appears to be safe treatment for hyperthyroidism without significantly increasing the risk of total cancer mortality.
In a study of 124 cases of malignant tumors of the thyroid, Skandalakis et al.159 found papillary carcinoma to be the largest group, accounting for 39.5%
They reported that this type of tumor is the least malignant.
In papillary carcinoma of the thyroid, Noguchi et al.160 stated that microscopic involvement of the cervical lymph nodes is 80%. Mirallié et al.161 presented
tables showing localization of lesion in papillary thyroid carcinoma (Tables 1-7, 1-8). Clark,162 in his invited commentary, made the following
recommendations: (1) The surgeon should look for nodes in the central neck; if present, they should be removed; (2) Therapeutic functional modified radical
neck dissection should be performed, with preservation of motor nerves in toto; (3) Prophylactic neck dissection should not be performed, since proportionally
few patients treated with irradiation develop nodal recurrence of metastases; (4) "Berry picking" is useless, since with palpable metastatic lymph nodes,
smaller nodes also have micrometastases.
Table 1-7. Localization of Node Involvement
No. in Node-Positive Patients
Node Localization Ipsilateral (n=71) Contralateral (n=30)
Paratracheal
60 (83.3%)
25 (34.7%)
Midjugular
44 (61.1%)
12 (16.7%)
Supraclavicular
26 (36.1%)
5 (6.9%)
Subdigastric
20 (27.8%)
2 (2.8%)
Source: Mirallié E, Visset J, Sagan C, Hamy A, Le Bodic MF, Paineau J. Localization of cervical node metastasis of papillary thyroid carcinoma. World J Surg 1999;23:970974; with permission.
Table 1-8. Node Involvement According to Localization of the Tumor in the Thyroid Lobe
No. by Site in Thyroid Lobe
Node
Upper Third Middle Third Lower Third Diffuse Unknown Isthmic
Ipsi paratracheal
9
6
10
18
14
3
Ipsi jugular
6
5
6
15
11
1
Ipsi supraclav
3
3
2
13
5
0
Ipsi subdig
7
1
1
5
5
1
Contralat paratrach 2
4
1
10
8
0
Contralat jugular
1
2
0
7
2
0
Contralat supraclav 0
2
1
2
0
0
Contralat subdig
0
0
1
1
0
0
Ipsi paratracheal: ipsilateral paratracheal nodes; Ipsi jugular: ipsilateral jugular nodes; Ipsi supraclav: ipsilateral supraclavicular nodes; Ipsi subdig: ispilateral
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Ipsi paratracheal: ipsilateral paratracheal nodes; Ipsi jugular: ipsilateral jugular nodes; Ipsi supraclav: ipsilateral supraclavicular nodes; Ipsi subdig: ispilateral
subdigastric nodes; Contralat paratrach: contralateral paratracheal nodes; Contralat jugular: contralateral jugular nodes; Contralat supraclav: contralateral
supraclavicular nodes; Contralat subdig: contralateral subdigastric nodes.
Source: Mirallié E, Visset J, Sagan C, Hamy A, Le Bodic MF, Paineau J. Localization of cervical node metastasis of papillary thyroid carcinoma. World J Surg 1999;23: 970974; with permission.
Read an Editorial Comment
Chen et al.163 reported that although rare, isolated metastatic disease to the thyroid gland from nonthyroid primary tumors have been observed, including
the following:
Renal cell carcinoma
5 cases
Esophageal adenocarcinoma
1 case
Pulmonary squamous cell carcinoma 1 case
Gastric leiomyosarcoma
1 case
Lingual squamous cell carcinoma
1 case
Parotid gland carcinoma
1 case
Boyd et al.164 recommend preoperative fine-needle aspiration of thyroid tumor as a powerful diagnostic tool for thyroid cancer. Tarantino et al.165 stated
that the role of fine-needle aspiration biopsy as well as flow cytometry for the evaluation of neck adenopathy has not been defined, but aspiration is reliable
for diagnosis of metastatic disease.
Matsuzuka et al.166 reported that the rare thyroid lymphoma may be detected by the Southern blot (IgH-JH or IgL-JÎ probes) in approximately 85% of the
cases.
Smith et al.167 described primary Hodgkin's disease of the thyroid gland and they found 19 similar cases in the literature.
Hermann et al.168 advised reoperation in recurrent hyperthyroidism, in the absence of contraindications, since this procedure is safe and effective.
Read an Editorial Comment
Lo et al.169 reported the following: "Patients with anaplastic carcinoma of thyroid have a dismal prognosis heralding imminent death. Surgical ablation followed
by adjuvant therapy can provide palliation for selected patients only." The senior author of this chapter (JES) had only one such case and despite the fact
that he cauterized and removed protruding anaplastic thyroid tissue daily and performed a tracheostomy, and despite irradiation, the patient died a few
months after surgery.
Dhar et al.170 reported that tumor microvascular densities perhaps is a new prognostic indicator for differentiated thyroid carcinoma. Dhar et al. indicated
that patients with thyroid carcinoma who have dThdPase expression and high tumor vascularity probably will need adjuvant radiotherapy.
Sanders and Silverman171 stated that follicular and Hürthle cell carcinoma of the thyroid gland with minimal capsular invasion behave in a benign way, and
both these types have a similar prognosis.
Gauger et al.172 stated as follows: "[T]he size of a follicular lesion cannot be used to predict a final diagnosis of follicular carcinoma and is of no value when
making intraoperative decisions about the extent of thyroid resection."
Invasion of the cervicovisceral axis (larynx, trachea, and esophagus) by thyroid carcinoma is a rare occurrence. According to Machens et al.,173 neoplastic
spread in this area is more often caused by extrathyroidal growth than by nodal metastasis. They recommend paratracheal and paraesophageal lymph node
clearance at primary operation.
In a study of patients who had undergone primary and reoperative surgery for sporadic medullary thyroid carcinoma, Gimm et al.174 advised transsternal
mediastinal lymph node dissection for those with lymph node metastases.
Hay et al.175 stated that bilateral thyroid lobectomy (BTL) for thyroid papillary carcinoma is the preferred initial surgical procedure over unilateral lobectomy
(UL) since the rates for local recurrence and nodal metastasis with UL are 14% and 19%, respectively, compared to 2% and 6% with BTL.
Hereditary medullary thyroid carcinoma should be treated with prophylactic total thyroidectomy during childhood; if calcitonin levels are elevated or if children
are older than 10 years, lymphadenectomy should be included according to Dralle et al.176
We quote from Kebebew et al.177 on reoperation of residual medullary thyroid carcinoma (MTC):
Although reoperation in patients with residual MTC rarely results in biochemical cure, cervical reexploration is safe and in selected patients may limit
MTC progression. Lateral cervical node dissection could be beneficial at the time of initial surgical treatment because of the high frequency of residual
MTC in the lateral cervical nodes. Noninvasive imaging studies were helpful but far from perfect for guiding the reexploration for locoregional residual
MTC.
Discussion of this paper included comments on lateral aberrant thyroid tissue, benign metastasizing goiter, and lateral anlages; monitoring of serum calcitonin
and CEA levels; and the importance of early operation for cure. We urge the interested reader to study this article in its entirety.
While Voutilainen et al.178 stated that there is currently no curative therapy for patients with anaplastic thyroid carcinoma, Nilsson et al.179 suggested that
a combination of preoperative hyperfractionated accelerated radiotherapy, doxorubicin pre- and postoperatively, and debulking surgery (when possible) may
produce better local control and, possibly, also increased survival rate.
For the management of amiodarone-associated thyrotoxicosis, a study by Hamoir et al.180 suggested that thyroidectomy is more effective than conventional
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medical treatment.
Chao et al.181 reported that most of the patients with thyroid carcinoma and concurrent hyperthyroidism have small carcinomas.
Shimizu et al.182 reported endoscopic resection of thyroid tumors in 5 patients.
For well-differentiated thyroid carcinomas invading the trachea, Yang et al.183 recommend surgical resection followed by primary reconstruction.
ANATOMIC COMPLICATIONS OF THYROIDECTOMY
Vascular Injury
Thyroid arteries must be ligated carefully; the superior thyroid artery tends to retract, thus filling the field with blood.
The superior thyroid artery should not be clamped above the upper pole of the thyroid because the external laryngeal nerve may be injured. If the artery is
clamped at the pole, a branch may escape, with resulting hemorrhage. The superior pole, together with the artery, should be clamped and ligated (Fig. 1-75).
Fig. 1-75.
The superior thyroid vessels should be clamped and divided within the substance of the upper pole of the thyroid gland. Failure to secure these vessels adequately
will result in massive hemorrhage. (Modified from Akin JT Jr, Skandalakis JE. Technique of total thyroid lobectomy. Am Surg 1976;42:648-656; with permission.)
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Separation of the inferior thyroid artery from the recurrent laryngeal nerve requires care. Where the nerve passes between branches of the artery, the
individual branches must be ligated and divided separately. Retraction of the artery can result in a hasty attempt at hemostasis that will injure the recurrent
nerve.
Avisse et al.131 reviewed 17 cases of right nonrecurrent inferior laryngeal nerve. An aberrant right subclavian artery was present in 2 cases. From their cases
and from a review of the literature the authors conclude that this arterial anomaly is always present with right nonrecurrent inferior laryngeal nerve. The
authors review the anatomic and embryologic bases and discuss the diagnostic and therapeutic implications of this double anomaly.
The middle thyroid vein is short and easily torn. If it is divided accidentally, it will retract, making hemostasis difficult. With too much traction of the thyroid
gland, the vein becomes flattened and bloodless, making it unrecognizable until it is severed. The tear is often at the junction of the middle thyroid vein and
jugular vein, presenting the danger of an air embolism. Such an injury to the vein requires immediate repair.
Bleeding during thyroglossal duct cyst surgery, pyramidal lobe excision, or division of a thick thyroid isthmus during thyroid surgery or tracheostomy is most
likely due to injury of the cricothyroid artery. This artery springs from the superior thyroid artery or from its anterior branch. It follows the upper border of the
cricothyroid muscle and membrane (Fig. 1-76).
Fig. 1-76.
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Nerves and arteries of the larynx, lateral view.
The thoracic duct is rarely injured in thyroidectomy, although injury during radical neck dissection is not unknown. The duct can be ligated with impunity.
Organ Injury
The pleura is rarely injured, but we have records of two patients in whom pneumothorax occurred. In one, a huge toxic goiter extended far laterally; in the
other, the thyroid was retrosternal.
Both anteriorly and posteriorly the two pleurae approach the midline, and hence each other. Intrathoracic goiter can descend into the anterior or posterior
mediastinum, bringing the thyroid gland close to the pleura (Fig. 1-77).
Fig. 1-77.
An enlarged, retrosternal thyroid gland showing its relation to the pleura (dotted line). (Modified from Harlaftis N, Tzinas S, Droulias C, Akin JT Jr, Gray SW,
Skandalakis JE. Rare complications of thyroid surgery. Am Surg 1976;42:645-647; with permission.)
Pandya and Sanders184 described a method whereby a Foley catheter was placed beyond the substernal component of the goiter. The catheter and its
inflated balloon were carefully tractioned upward, delivering the substernal goiter in the neck. This procedure was used safely and successfully on two
patients, thereby preventing the need for a sternotomy. Though the reported use of this procedure is very limited, perhaps the procedure is sound.
The trachea and esophagus can be injured in the presence of thyroiditis, calcified adenoma, or malignancy. The true capsule of the thyroid, the pretracheal
fascia, the trachea, and the esophagus can be so fixed to one another that vigorous attempts at separation may perforate the trachea. A tracheal
perforation may require immediate tracheostomy.
The parathyroid glands are close to the posterior thyroid capsule. With total conservative thyroidectomy, hypocalcemia occurs in 20 to 25 percent of
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The parathyroid glands are close to the posterior thyroid capsule. With total conservative thyroidectomy, hypocalcemia occurs in 20 to 25 percent of
patients.185,186 In most of these the drop in calcium (perhaps owing to trauma to the glands) is small and transitory; it persists in 1-4 percent of cases. In
radical thyroidectomy, the incidence is higher. Preservation of only one parathyroid gland will avoid the symptoms of hypoparathyroidism.
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Nerve Injury
Vagus Nerve
Fernando and Lord187 presented data to indicate that inadvertent interruption of the vascular supply of the vagus nerve could be the hitherto unsuspected
cause of several neurologic problems following thyroidectomy, carotid endarterectomy, and surgery for correction of aortic arch aneurysms. It is possible that
some postoperative neurologic problems attributed to accidental injury of the recurrent laryngeal nerve might have actually resulted from ischemia or edema
of the vagus nerve, with similar results (Figs. 1-78, 1-79, 1-80, and 1-81).
Fig. 1-78.
Dissection of the right side of the human neck. The large vagal artery (A) receives reinforcing branches (R) from the common (B) and internal (I) carotid arteries.
Inadvertent damage to these vessels in carotid endarterectomy may account for injury to the vagus nerve (N) and subsequent vagal palsy. (Modified from Fernando
DA, Lord RSA. The blood supply of the vagus nerve in the human: its implication in carotid endarterectomy, thyroidectomy and carotid arch aneurectomy. Ann Anat
1994;176:333; with permission.)
Fig. 1-79.
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Neck dissection of the human. A large vagal vein (V) drains venous blood to the superior (S) and inferior (I) thyroid veins. Interruption to these vessels in
thyroidectomy may account for vagal damage leading to voice changes. The vagus nerve is indicated by N. (Modified from Fernando DA, Lord RSA. The blood supply of
the vagus nerve in the human: its implication in carotid endarterectomy, thyroidectomy and carotid arch aneurectomy. Ann Anat 1994;176:333; with permission.)
Fig. 1-80.
Neck dissection of the human. The prominent vagal vein (V) drains into the inferior thyroid vein. The vagal artery arising from the inferior thyroid artery lies alongside
the vein. Sutures placed distal to the point of opening of the vagal vein or the commencement of the vagal artery may result in degenerative changes or edema of
the vagus with consequent vagal palsy. The vagus nerve is indicated by N. (From Fernando DA, Lord RSA. The blood supply of the vagus nerve in the human: its
implication in carotid endarterectomy, thyroidectomy and carotid arch aneurectomy. Ann Anat 1994;176: 333; with permission.)
Fig. 1-81.
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Dissection of the left side of the neck and thorax. The large vagal artery (A) arises from the inferior thyroid artery. This vessel bifurcates into ascending and
descending branches. The descending branch receives reinforcing twigs from the aorta, bronchial, and esophageal arteries. Damage to these small vessels in
thyroidectomies and removal of aneurysms of the aortic arch may also contribute to vagal damage and consequent symptoms of vagal palsy and voice changes. The
vagus nerve is indicated by N; common carotid artery by B. (Modified from Fernando DA, Lord RSA. The blood supply of the vagus nerve in the human: its implication
in carotid endarterectomy, thyroidectomy and carotid arch aneurectomy. Ann Anat 1994;176:333; with permission.)
According to the same authors, the cervical and thoracic parts of the vagus have a single large vagal artery, most commonly on the anteromedial side of the
nerve, which is formed by contributions at several levels. Superiorly, the vagus receives a branch from the posterior inferior cerebellar artery. Inferiorly, it is
supplied by a branch from the inferior thyroid artery (the main trunk of the vagal artery). In between, the vagus receives reinforcing twigs directly from the
common carotid and internal carotid arteries at 1.5 cm intervals. The vagal veins drain into the superior and inferior thyroid veins. Vagal palsy follows
approximately 27% of carotid endarterectomies. The type of damage to the vagus nerve is comparable to that of the spinal cord with interruption of radicular
branches.
Fernando and Lord187 also wrote that ligating the inferior thyroid artery close to its origin will interrupt the principal supply to the vagus (which typically
arises 2-3 cm from the inferior thyroid's origin). Ligation of the venous drainage of the nerve results in edematous changes and nerve palsy.
Recurrent Laryngeal Nerve
In a series of thyroid operations in which 217 recurrent laryngeal nerves were involved, Holt and coworkers188 found 9 nerve injuries, of which 4 were
permanent. In the same series there were three injuries to superior laryngeal nerves; one was permanent.
Most recurrent laryngeal nerve injuries occur "just below that point where the nerve passes under the lower fibers of the inferior constrictor muscle to
become intralaryngeal."189 The usual cause is a hemostatic stitch.137 Another source of injury is mass ligation of the vessels of the lower pole of the thyroid.
Such ligation may include a recurrent nerve more anterior than usual. The nerve should be identified before ligating the inferior thyroid vein. The specific
causes of recurrent laryngeal nerve injury have been evaluated by Chang-Chien190 (Table 1-9).
Table 1-9. Recurrent Laryngeal Nerve Vulnerability
Cause of Vulnerability
Percent Encountered
Lateral and anterior location
1.5-3.0
Tunnelling through thyroid tissue
2.5-15.0
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Tunnelling through thyroid tissue
2.5-15.0
Fascial fixation
2.0-3.0
Arterial fixation
5.0-12.5
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Close proximity to inferior thyroid vein 1.5-2.0+
Data from six series of Chang-Chien Y. Surgical anatomy and vulnerability of the recurrent laryngeal nerve. Int Surg 65:23, 1980.
Source: Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.
The results of injury to the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve have been outlined by Esmeraldo and
coworkers.191
In unilateral recurrent nerve injury, the affected vocal cord is paramedian in position due to tension on the vocal ligament by the cricothyroid muscle. Voice is
preserved (not unchanged).
With unilateral injury to both the recurrent laryngeal and superior laryngeal nerve the affected cord is in an intermediate position, resulting in hoarseness and
inability to cough. The affected cord will move toward the midline with time. Voice improves, but is followed by narrowing of the airway. Loss of the superior laryngeal
nerve leaves the tissues of the larynx and piriform recesses insensate, resulting in loss of the cough reflex and difficulties with aspiration and clearing the airway.
With bilateral recurrent nerve injury, because of the narrowing of the airway produced by unopposed cricothyroid muscles, tracheostomy becomes necessary.
Scanlon and colleagues186 reported a series in which 6 of 245 patients who had undergone total thyroidectomy experienced recurrent laryngeal nerve
paralysis. All but one recovered within a year.
Postoperative hoarseness is not always the result of operative injury to laryngeal nerves. From 1 to 2 percent of patients have a paralyzed vocal cord prior
to thyroid operation.188 Neel and coworkers at the Mayo Clinic 192 examined 202 cases of vocal cord paralysis, of which 153 (76 percent) followed
thyroidectomy, 36 (18 percent) were of various known etiologies, and 13 (6 percent) were of idiopathic origin. We strongly advise the general surgeon to
have an indirect laryngoscopy performed prior to thyroidectomy.
Miyauchi et al.133 performed ansa cervicalis-recurrent laryngeal nerve anastomosis in the neck for vocal cord paralysis due to mediastinal lesions. They
reported excellent improvement in phonation without vocal cord movement.
We believe that the patient should be told that in spite of all precautions, there is a possibility that there may be some vocal disability following
thyroidectomy. Dysphagia can result from damage to early rising branches of the recurrent laryngeal nerves that supply the esophagus.193
Superior Laryngeal Nerve
Lekacos et al.194 noted 3 cases of superior laryngeal nerve injury after 54 classical high ligations of the superior thyroid artery. They observed that patients
with loss of the external laryngeal nerve complained of voice instability, quick vocal fatigue and inability to produce high-pitched sounds, with difficulty in
singing. No injuries were recorded in 227 other cases in which the branches of the superior thyroid artery were ligated at the superior pole. According to
Durham and Harrison,195 the external laryngeal nerve closely parallels the superior thyroid vessels in about 20% of cases, and even passes between the
branches of the superior thyroid artery near the superior pole in 6-14% of cases.
In their excellent monograph, Johns and Rood196 discussed classification of the paralyzed vocal cord. The paralyzed vocal cord may be paramedian
(interruption of the recurrent laryngeal nerve alone [Wagner-Grossmann theory]) or intermediate (interruption of the recurrent and superior laryngeal nerves).
Injury to the superior laryngeal nerve alone can be identified by rotation of the superior glottis to the affected side, and by bowing of the vocal cord.
We agree with the statement of Johns and Rood:
. . .A thorough understanding of the anatomy of the larynx and the relationships of the laryngeal nerve supply to the intrinsic muscles of the larynx is a
prerequisite to adequate localization of the site of lesion in laryngeal nerve injury. Successful management of the patient is based upon an accurate
etiologic diagnosis.196
Cervical Sympathetic Chain
A sympathetic ganglion can be confused with a lymph node and can be removed when the surgeon operates for metastatic papillary carcinoma of the thyroid.
In one of our patients, inferior cervical and first thoracic ganglia were fused to form a nodelike structure that was removed.197 The surgeon must identify any
apparent lymph node related to the vertebral artery and fixed in front of the transverse process of the 7th cervical vertebra.
Injury to the cervical sympathetic nerve results in Horner's syndrome: (1) constriction of the pupil, (2) partial ptosis of the upper eyelid, (3) apparent
enophthalmos, (4) dilatation of the retinal vessels, and (5) flushing and drying of the facial skin on the affected side.
Thyroidectomy of large goiters will be facilitated by division (high, middle or low) of the infrahyoid muscles. The expectation is that injury to the ansa
cervicalis will thus be avoided. High division was recommended by Farquharson and Rintoul198 and Paparella and Shumrick,199 middle division by Wilson,200
and low division by Stell and Maran.201
The formation and location of the ansa cervicalis is variable. We have seen a singular root in one case, which is a rare phenomenon. In most cases, there are
two roots which unite; segmental branches spring from this union. The pathway of these branches is quite variable; therefore there is no "typical" segmental
innervation of the infrahyoid muscles. The sternohyoid and sternothyroid muscles are innervated by branches that spring after the union of the upper
descendent root (C1) and the lower descendent root (C2, C3) of the ansa cervicalis (Fig. 1-82). The entrance of the motor branch of these two muscles is
characteristically in the vicinity of the thyroid cartilage, and just above the jugular notch, or, rather, bisecting the angle between the inferior segment of the
sternohyoid muscle and the clavicle.
Fig. 1-82.
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A plan of the right hypoglossal nerve and ansa cervicalis.
For all practical purposes we do not know the topography of the union and the pathway of the branches of the ansa cervicalis in a given patient. Therefore,
we must prepare carefully for facilitating thyroidectomy by unilateral or bilateral division of the four infrahyoid or strap muscles which are innervated by the
ventral rami of C1, C2 and C3 via the hypoglossal nerve (Fig. 1-83). The muscles should ordinarily be divided high to protect their nerve supply. By all means
we agree with Beahrs et al.23 that the integrity of these four muscles should be preserved.
Fig. 1-83.
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The ansa cervicalis, its roots, and its branches to the infrahyoid muscles.
In our practices we occasionally divide the muscles; the point of division varies depending on the size of the megathyroid. While our postoperative
observations might have been superficial, we never noticed any changes in voice, deglutition, or mastication. When these four muscles are paralyzed, the
hyoid bone and laryngeal apparatus malfunction and impair swallowing.
We strongly advise the interested student to carefully read the papers of Yerzingatsian.202,203
Chao et al.204 reported that the uncommon procedure of reoperative thyroid surgery can be safely performed with little morbidity to the patient.
Postoperative complications were as follows:
Transient hypoparathyroidism
5.2%
Permanent hypoparathyroidism
1.7%
Transient recurrent laryngeal nerve palsy
2.6%
Permanent recurrent laryngeal nerve palsy 1.7%
We quote from Profanter et al.205 on primary hyperparathyroidism (HPTH):
Sonography had an overall accuracy to correctly localize enlarged parathyroid glands of 80%, and scintiscanning had overall accuracy of 78.6%. The
accuracy of localization was increased up to 84.6% if both diagnostic procedures were applied. In patients with normal thyroid residues the accuracy
of sonography was 85.7%, and it was 100% if scintiscanning was used. . . Preoperative localization techniques in patients with primary HPTH and
previous thyroid surgery have high accuracy. This allows for an imaging- directed operative strategy, thus preventing unnecessary bilateral neck
explorations, which carry a high risk of recurrent laryngeal nerve injury.
We quote from Menegaux et al. about secondary thyroidectomy:206
The permanent complication rate is higher in thyroid reoperations than in primary thyroid operations. However, we believe that this 2% rate is low
enough to allow reoperation whenever it is necessary, provided precise operative rules are respected.
PARATHYROID GLANDS
EMBRYOGENESIS
Normal Development
In the fifth and sixth weeks of gestation the embryonic pharynx is marked externally by four branchial clefts of ectoderm. Internally there are five branchial
pouches of endoderm. These clefts and pouches, together with the branchial arches between, compose the branchial apparatus. Although transitory, the
apparatus leaves some normal derivatives: the thyroid and parathyroid glands, thymus, ultimobranchial body, eustachian tube, middle ear, and external
auditory canal. There is also the possibility that some normally transient structures will persist into adulthood.
The parathyroid glands develop as epithelial thickenings of the dorsal endoderm of the third and fourth branchial pouches. As a result of their subsequent
migration, the derivatives of the third pouch become the inferior parathyroids (parathyroids III), while those of the fourth pouch become the superior
parathyroids (parathyroids IV) (Fig. 1-84). Both primordia descend from their level of origin, but parathyroids III are closely associated with the thymus gland
derived from the ventral portion of the third pouch. This association usually ends in the eighth week, leaving the parathyroid gland near the level of the lower
border of the thyroid gland. Occasionally, parathyroids III become encapsulated with the thymus and may be carried into the mediastinum. This is of no
significance to the patient, but it may be frustrating for the surgeon.
Fig. 1-84.
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The migratory pathways of the parathyroid glands. The glands may be found at any point along those pathways, usually at the levels indicated by the horizontal
arrows. (Modified from Gray SW, Skandalakis JE, Akin JT Jr. Embryological considerations of thyroid surgery: Developmental anatomy of the thyroid, parathyroid, and
the recurrent laryngeal nerve. Am Surg 1976;42:621-628; with permission.)
The following points are important to consider:
Is the genesis of the parathyroid glands of ectodermal origin, and therefore from pharyngeal clefts 3 and 4? Maybe.
Do the parathyroid glands arise from the neural crest, meaning they belong to the APUD system? Maybe.
Lundgren et al.207 demonstrated that the abnormal parathyroid tissue of normocalcemic primary hyperparathyroidism is characterized by morphologic and functional
derangements. These are consistently seen in patients with primary hyperparathyroidism and hypercalcemia.
Congenital Anomalies
Abnormal parathyroid development includes variations in location, number, shape, size, weight, and color. Parathyroid cysts may be congenital. The LobdellDiGeorge syndrome (agenesis of the parathyroid and thymus) is an anomaly which involves the caudad branchial arches and pouches, and presents with
approximately 38 combinations.
Figure 1-85 illustrates the anatomic locations of ectopic parathyroid glands found in a study by Shen et al.208 The procedure for locating such glands is
presented in "Strategy for Finding Parathyroid Glands" later in this chapter. Casas et al.,209 Malhotra et al.,210 and Martin et al.211 advised preoperative
parathyroid localization with technetium-99m-sestamibi scan. This not only may reduce operative time, but also may contribute to successful surgery.
Fig. 1-85.
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Anatomic locations of ectopic parathyroid glands, with number found in each location (n=54). (Modified from Shen W, Düren M, Morita E, Higgins C, Duh QY, Siperstein
AE, Clark OH. Reoperation for persistent or recurrent primary hyperparathyroidism. Arch Surg 131:861-869; with permission.)
SURGICAL ANATOMY
General Topographic Anatomy
The parathyroid glands are usually found on the posterior surface of the thyroid gland, each with its own capsule of connective tissue. They are occasionally
included in the thyroid capsule, or one of them may even follow a blood vessel deep into a sulcus of the thyroid.
The frequency of such occult glands is not known. Farr and associates212 found 10 examples among 100 patients with parathyroid tumors. Few intrathyroid
parathyroid glands are discovered in the absence of disease. Several techniques have been developed for locating occult parathyroid glands.213,214
McIntyre et al.215 reported that 18 of 309 patients (6%) who had undergone parathyroidectomy had intrathyroidal parathyroid glands. Libutti et al.216
reported an intrathyroidal parathyroid gland in 7 percent of the cases and they advise ultrasonography for selection of patients for thyroid resection.
Gray et al.217 tabulated the adult position of 200 parathyroid glands in 50 cadavers. Table 1-10 shows the location of these glands, all of which could be
considered "normal."
Table 1-10. Location of Parathyroids in 50 Cadavers
Location on Thyroid Gland
Superior Parathyroids, % Inferior Parathyroids, %
Upper third
8
2
Middle third
80
12
Lower third or below inferior pole 12
86
100
100
Source: Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.
Extreme locations are very rare, although glands have been found as high as the bifurcation of the carotid artery and as low as the mediastinum.139 In
practice, the surgeon should start at the point at which the inferior thyroid artery enters the thyroid gland. The superior parathyroid glands will probably lie
about one inch above it, and the inferior parathyroid glands will probably lie one-half inch below it. If the inferior gland is not found, it is more likely to be
lower than higher.
Typically there are four parathyroid glands, but it is fairly common to have more or fewer. When fewer than four glands are found, the possibility of ectopic
glands is hard to rule out. Two parathyroid glands can be fused to one another; such a pair can be differentiated from a bilobate gland by the presence of a
cleavage plane between them.139
Hooghe et al.218 reported that in 416 parathyroidectomies, 19% of the organs were found in ectopic locations, such as distant to the thyroid lobes, along
the esophagus, or in the upper anterior mediastinum within thymic remnants. Among Hooghe's patients, 5% had supernumerary parathyroids. Parathyroid
tissue within the thymus with primary hyperthyroidism was reported by Wei et al.219
McHenry et al.220 studied parathyroid localization with technetium-99m-sestamibi, and reported that the sensitivity and positive predictive value of this
scintigraphic technique is comparable to or better than other localization procedures. The same authors reported that the test's lack of sensitivity for the
detection of multiglandular disease precludes its use for bilateral routine exploration in patients with hyperparathyroidism.
Although CT, MRI, and technetium-99m/thallium-201 have been used for identifying the glands' primary hyperparathyroidism, the search continues for better
imaging modalities. Bonjer et al.221 explored the possibility of using 2-methoxyisobutylisonitrile (MIBI) labeled with technetium-99m scanning as a preoperative
and intraoperative technique using a hand-held gamma probe. Despite the fact that Bonjer and colleagues concluded that the MIBI probe did not improve the
outcome of parathyroid surgery in their study, we agree with the invited commentary of Linos221 that there is room for improvement of this technique and
that the probe should continue to be used. Indeed, Purcell et al.222 have reported a high degree of success using a combination of high-resolution ultrasound
and technetium Tc99 sestamibi scanning to locate the parathyroids before surgery in patients with hyperparathyroidism.
Read an Editorial Comment
Szabo et al.223 found in a retrospective study of 659 patients with sporadic primary hyperparathyroidism that the incidence of parathyrodid adenoma in two
enlarged parathyroid glands was approximately 12%.
Read an Editorial Comment
Pre-operative localization of parathyroid adenomas is even more difficult when thyroid nodules are present. Krausz et al.224 advise that in the absence of
thyroid pathology, high-resolution ultrasonography should be the first step for localization of a parathyroid adenoma prior to surgery. They reported that in
patients with primary hyperparathyroidism alone, scintigraphy with technetium-99m-sestamibi is an effective diagnostic tool. Scintigraphy and
ultrasonography are needed when the patient has thyroid abnormalities in addition to hyperparathyroidism.
Vascular Supply
Alveryd225 studied parathyroid arterial supply in 354 autopsy specimens. It was observed that both the superior and inferior parathyroids are usually supplied
by the inferior thyroid artery: 86.1% on the right side, 76.8% on the left. In the absence of an inferior thyroid artery, both the superior and inferior
parathyroid glands were supplied by the superior thyroid artery in the majority of cases225 (Fig. 1-86, Table 1-11). After a study of 160 autopsy specimens,
Wang139 stated that the vascular pedicle could be used to locate a low-lying parathyroid IV (Fig. 1-87).
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Wang
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stated that the vascular pedicle could be used to locate a low-lying parathyroid IV (Fig. 1-87).
Table 1-11. Variations in Vascular Supply of 1405 Parathyroids Identified at 354 Autopsiesa,b
Right Side
Left Side
1 Parathyroid 2-3 Parathyroids Total 1 Parathyroid 2-3 Parathyroids Total
Inferior thyroid artery
12.4 c
86.4
98.8
20.1 c
76.8
96.9
Superior thyroid artery
8.7
0.6
9.3
15.0
2.8
17.8
Thyroid ima artery
0.6
0.6
0.6
0.6
Artery from larynx, trachea, esophagus, or mediastinum 1.7
1.7
2.0
2.0
a From
b
Alveryd A. Parathyroid gland in thyroid surgery. Acta Chir Scand 1968;389 (suppl):1-120.
The figures indicate the frequency in percent of total number of cases.
cIncludes
10 cases (right side) and 13 cases (left side) in which only one gland was identified.
Source: Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.
Fig. 1-86.
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A, Schematic drawings showing the positions of the parathyroid glands and their vascular supply in 12 cases with 5 parathyroids without adenoma. The right and
left parathyroids are indicated separately in each case. B, Variations in the location of the parathyroid glands in relation to the inferior artery on both sides in 354
cases with 2-5 glands. The schematic drawings show a lateral view of the larynx and trachea with the thyroid mobilized and dislocated ventrally and medially. Dotted
horizontal lines indicate the levels of the entrance of the uppermost and lowermost branches of the inferior artery in the thyroid parenchyma. The hatched areas
indicate the location of the parathyroids. For the sake of completeness, the cases without an inferior thyroid artery are also registered in separate drawings, but in
these the location of the parathyroid is not shown. (Modified from Alveryd A. Parathyroid gland in thyroid surgery. Acta Chir Scand (suppl) 1968;389:1-120; with
permission.)
Fig. 1-87.
A. A to C. Anatomic distribution of 312 upper parathyroid glands (parathyroid IV). B. A to D. Anatomic distribution of 312 lower parathyroid glands (parathyroid III).
(Modified from Wang C. The anatomic basis of parathyroid surgery. Ann Surg 1976;183:271; with permission.)
As noted previously, Nobori et al.109 found that a branch from the superior thyroid artery that anastomosed with the inferior thyroid artery supplied the
superior parathyroid gland in approximately 45% of cases. The greater frequency of supply by the superior thyroid artery seen in the work of Nobori et al. in
contrast to that of others could be attributable to the techniques used or perhaps to genetic differences in anatomy.
Delattre et al.226 found that the blood supply to the parathyroids seems to originate as follows:
Superior parathyroids:
77.1% - Inferior thyroid artery
15.3% - Anastomosis of inferior and superior thyroid arteries
Inferior parathyroids:
90.3% - Inferior thyroid artery
Ander et al.227 studied the blood supply and parathyroid hormone secretion in patients with parathyroid adenoma or secondary hyperplasia. They reported
that, despite devascularization, increased parathyroid hormone secretion remained unchanged.
Innervation
The innervation of the parathyroid glands is either direct from the superior or middle cervical ganglia, or through a plexus in the fascia on the posterior lobar
aspects.
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aspects.
HISTOLOGY AND PHYSIOLOGY
The major portion of the parathyroid parenchyma is formed by the principal cells and a minor part is formed by oxyphilic cells. Perhaps all the parathyroid cells
participate in the secretion of the parathyroid hormone, parathormone (PTH), and in the regulation of calcium and phosphate metabolism. We strongly advise
the interested student of the parathyroids to read the excellent paper of Weber et al.,228 which suggests that the PTH content of parathyroid tissue may be
of use in differentiating normal from abnormal organs.
To maintain normal calcium in the blood, a feedback system is formed between the circulating calcium and the secretion of PTH. Too much serum calcium
inhibits production of PTH; too little stimulates secretion.
Cisneros et al.229 stated that in patients with nonmetastatic squamous cell carcinoma of the skin, humoral hypercalcemia of malignancy (tumor hormone
secretion into the systemic circulation distant to the skeleton with subsequent bone resorption) can be produced by parathyroid hormone-related protein
(PTHrP).
We quote from Perez and Pazianos230:
[T]he absence of an elevated PTH level in the presence of hypercalcemia should exclude primary hyperparathyroidism as the cause. Rarely....the PTH
level, although in the normal range, is considered too high for nonparathyroid hormone-mediated cause of hypercalcemia other than primary
hyperparathyroidism. To the best of our knowledge, the mediator involved in the parathyroid glands of these subjects is unknown.
However, we agree with LiVolsi231 who stated that "our understanding of parathyroid pathophysiology is far from complete. As suggested by the authors of
this study, information from molecular biology studies of calcium-sensing receptors and the genes regulating calcium sensitivity in parathyroid tissue (both
normal and abnormal), remains to be defined."
SURGERY OF THE PARATHYROIDS
The most common indication for parathyroid surgery is hyperparathyroidism. Very rarely parathyroid cysts are associated with hyperparathyroidism, but these
cysts have never been found to be malignant.
A case of a functioning parathyroid cyst was presented by Safran;232 this review stated that Mitmaker reported only 162 cases of parathyroid cysts in the
literature in 1991, with a lower incidence of functioning cysts. Safran recommended aspiration of these cysts, which present as masses at the lateral or lower
neck. Hypercalcemia, hypophosphatemia, and elevated serum parathormone are always present, but disappear after the removal of the cyst.
Read an Editorial Comment
Malignancy of the parathyroids is, of course, rare but may involve one or more parathyroids. Surgeons should decide in the operating room how radical a
procedure they will use and whether removal of adjacent anatomic entities is necessary.
Strategy for Finding Parathyroid Glands
The normal location of the superior and inferior parathyroid glands has been described. Traynor et al.233 found that rapid uptake of methylene blue by the
parathyroid glands suggests that selective intraoperative use when glands are difficult to locate intraoperatively, rather than a routine preoperative infusion,
is possible without significant operative delay. General surgeons must take specific steps to find the glands, however, because they cannot explore the entire
neck. The following steps are essentially those suggested by Adams,234 Cady,235 McGarity and Bostwick,236 and Edis:237
Step 1. Explore the superior surface of the thyroid gland. Ligate the middle thyroid veins, retract the lobe medially and anteriorly, and expose the recurrent
laryngeal nerve.
Step 2. Dissect the superior mediastinum as far as possible, with special attention to the thymus or its remnant behind the manubrium.
Step 3. Explore the region above the upper pole of the thyroid gland as far as the hyoid bone.
Step 4. Explore the retroesophageal and retropharyngeal spaces.
Step 5. Perform subtotal thyroidectomy.
Step 6. Further explore the mediastinum at a second operation. This should be done only after the pathology report on thymus and thyroid tissue has been
received and no parathyroid tissue is reported.236
The order of these steps, especially steps 5 and 6, is controversial. In a series of 400 operations reported by Nathaniels and colleagues,238 there were 84
mediastinal parathyroid tumors. Of these, 19 required mediastinotomy. Sixty-seven were in the anterior mediastinum, and 17 were in the posterior
mediastinum. The remainder were removed through a neck incision. We believe mediastinal exploration should be the procedure of last resort.
Surgical Applications
Preoperative localization of the parathyroid glands is a tremendous help for both patient and surgeon. Gupta et al.239 advise that preoperative 99m-technetium
sestamibi (MIBI) localization of simple parathyroid adenoma with hyperparathyroidisms will reduce not only operative time but also the extent of surgical dissection
and risk.
Farnebo et al.240 stated that Ki-67 (cell-cycle associated antigen) may give valuable information as to the malignant potential of parathyroid tumors, whereas
retinoblastoma protein immunoreactivity has not proven useful in distinguishing between benign and malignant parathyroid tumors.
Ryan et al.241 stated that after localization of the parathyroid adenoma a unilateral neck exploration produces results similar to bilateral exploration, and requires
less operative time.
Angelos et al.242 reported a very unusual case of a patient with hyperparathyroidism who experienced spontaneous left recurrent laryngeal nerve paralysis after
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Angelos et al.242 reported a very unusual case of a patient with hyperparathyroidism who experienced spontaneous left recurrent laryngeal nerve paralysis after
which his hypercalcemia resolved. After removal of a parathyroid adenoma with abscess formation the vocal cord function returned.
Richards et al.243 reported the ninth case of spontaneous infarction of a parathyroid adenoma in primary hyperparathyroidism. The anatomy of the infarction is
enigmatic. The above authors speculate that perhaps the infarction is secondary to the tumor outgrowing its blood supply. Thrombosis of the parathyroid blood
supply was reported by Dowlatabadi.244
Billingsley et al.245 used the term "parathymic" to designate an undescended parathyroid gland that is located high in the neck just below or above the carotid
bifurcation. Embryologically the term is correct, since the inferior parathyroids and the thymus arise from the third pharyngeal pouch. However, the term will confuse
the surgeon who is not familiar with the ontogenic location of the parathyroid glands and who may think it refers to a "thymic" location of the parathyroid.
For the treatment of familial hyperparathyroidism, Barry et al.246 advised subtotal parathyroidectomy and routine transcervical thymectomy.
Proye et al.247 stated that patients with primary hyperparathyroidism and multiple gland enlargement may be treated by conservative surgery, resecting only the
grossly enlarged glands and not biopsying the normal looking glands.
Chen et al.248 reported that parathyroidectomy in elderly patients (over 70 years) can be performed with high cures, low morbidity, no mortality, short length of
stay, and high patient satisfaction.
Pasieka and Parsons 249 reported that parathyroidectomy reduces preoperative symptomatology in patients with primary hyperparathyroidism, with the most
marked improvement occurring within the first 10 days after surgery.
Ryan and Lee 250 emphasized the effectiveness and safety of 100 consecutive parathyroidectomies in normalizing serum calcium.
Angelos 251 studied patients with primary hyperparathyroidism who were evaluated by preoperative scintigraphy. After excluding several patients based on their
histories, the remaining patients with positive scans underwent successful radioguided operations, while those with negative scans had successful standard
parathyroidectomies. Angelos concluded, "Although radioguided parathyroid surgery is an effective surgical approach...[s]tandard four gland exploration will continue
to be needed for many patients."
Miccoli et al.252 recommended endoscopic parathyroidectomy after preoperative localization of parathyroid lesions and intraoperative parathyroid hormone assay.
They had good results in 39 patients.
Starr et al.253 reported that intraoperative measurement of intact parathyroid hormone to measure adequacy of resection of hyperfunctioning tissue during
parathyroidectomy decreased the harvesting of frozen sections, but did not improve the rate of normalization of serum calcium.
Zaraca et al.254 stated that total parathyroidectomy with autotransplantation in 19 patients with severe secondary (renal) parathyroidism relieves the
hyperthyroidism symptoms, and the recurrence rate of hyperparathyroidism is low.
Mollerup and Lindewald 255 stated that primary hyperparathyroidism and renal stone disease are common, but a number of patients experience recurrence of their
stone disease in the presence of normal calcium rates after successful parathyroidectomy.
Caccitolo et al.256 believe that the correction of postexploration hypocalcemia using cryopreservation and autotransplantation is sound in theory, but difficult in
practice.
Since hyperparathyroidism may develop after autotransplantation of histologically normal parathyroid tissue, or after a period of postsurgical hypoparathyroidism,
D'Avanzo et al.257 stresses the importance of marking the site of parathyroid transplantation.
Using endoscopic laser technology, Stojadinovic et al.258 removed a parathyroid adenoma which was located in the piriform recess.
Although long periods of remission are possible after subtotal parathyroidectomy, Burgess et al.259 reported that recurrent hyperparathyroidism eventually
develops in most patients with multiple endocrine neoplasia type I (MEN I).
Rates of successful surgery for primary hyperparathyroidism are shown in Table 1-12.
Kikumori et al.260 reported that grafting of the parathyroids with total thyroidectomy is successful and that the glands fuction for a long time.
Table 1-12. Successful Surgery for Primary Hyperparathyroidism
Procedure
Success Rate Investigator
Initial operation
95%
Clark et al.351
Edis et al.352
Martin et al.353
Granberg et al.354
Reoperation without localization prior to surgery
60%
Satava et al.355
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Reoperation with localization prior to surgery by noninvasive techniques 89%
Satava et al.
Grant et al.356
NOTE: According to Cheung et al.357 and Sugg et al.,358 invasive techniques such as arteriography and selective venous sampling fail to localize the abnormal
parathyroid gland.
ANATOMIC COMPLICATIONS OF PARATHYROIDECTOMY
The complications of parathyroidectomy are the same as those associated with thyroidectomy (previously considered in this chapter) and radical neck
surgery (to follow later in this chapter).261,262
Failure to find an adenomatous gland in the presence of hyperparathyroidism is evidence of an inadequate procedure. Hellström and Ivemark263 reported
failure to find the diseased gland in 10 percent of 92 patients.
To avoid repeated parathyroidectomies, Shen et al.208 advised bilateral cervical exploration and preoperative localization.
Lo and Lam264 advised immediate autotransplantation of parathyroid glands to avoid hypoparathyroidism. The same authors cautioned that routine
autotransplantation was associated with a high incidence of postsurgical hypocalcemia.265
Berger et al.266 stated the following:
There is a marked heterogeneity in gland size in patients with sporadic multigland hyperplasia, which is similar to that found in multiple endocrine
neoplasia type I. This heterogeneity may result in failure to recognize multigland disease if a unilateral neck exploration is performed. Intraopertive
parathyroid hormone assay may prove to be an important adjunct in this population of patients who have unsuspected multigland disease.
TRACHEA AT THE NECK
EMBRYOGENESIS
Normal Development
There is confusion in the literature regarding the use of the terms ventral and dorsal wall of the foregut. Remember: the respiratory diverticulum appears at
the ventral wall of the foregut, but by separation later and the formation of the esophagopharingeal border, the foregut is divided in two portions: ventral,
which is responsible for the genesis of the respiratory system, and dorsal, which is responsible for the genesis of the esophagus.
At the end of the third week of gestation, the laryngotracheal groove appears on the ventral surface of the upper end of the embryonic foregut. The distal
end of the groove grows caudad, while the proximal end and the foregut grow cephalad. The trachea (anterior) and the esophagus (posterior) become
separated caudally; in the fourth week, the lung buds appear at the tip of the tracheal primordium. At first the tracheal bifurcation is high in the cervical
region; at birth it will be at the level of the 4th or 5th thoracic vertebra.
Cartilage appears in the trachea and primary bronchi in the tenth week, and glands appear a week later.267,268
Congenital Anomalies
The trachea is rarely subject to anomalies. Tracheoesophageal fistula is the only defect frequently encountered. Its repair does not fall into the field of the
general surgeon.
Vascular compression of the trachea was reported by Burch et al.269
SURGICAL ANATOMY
General Structure
The trachea, together with the esophagus and thyroid gland, lies in the visceral compartment of the neck. The anterior wall of the compartment is composed
of sternothyroid and sternohyoid muscles. It is covered anteriorly by the investing layer of the deep cervical fascia and posteriorly by the pretracheal fascia
(see Fig. 1-26). The trachea begins at the level of the sixth cervical vertebra. Its bifurcation is at the level of the sixth thoracic vertebra in the erect
position, or the fourth to fifth thoracic vertebrae when supine.
There are 16 to 20 tracheal cartilages. The cervical part of the trachea consists of 4 or 5 incomplete rings of cartilage and their connecting membranes,
smooth muscle fibers, and fibroelastic tissue completing the arches posteriorly. The smooth muscle fibers are arranged horizontally, attaching to the
perichondrium of the end of the cartilage. In this way, contraction of the muscle narrows the lumen of the trachea. The posterior surface of the trachea,
formed by the fibromuscular membrane, is therefore flat.
The cartilages are about 4 mm high and about 1 mm thick. In some cases the cartilages of two or more rings fuse, usually only partially. In some cases the
ends of the cartilage may bifurcate. The highest of the tracheal rings is attached to the cricoid cartilage by the cricotracheal membrane. This is the widest
of the tracheal cartilages. The diameter of the trachea is greater in men than in women, and is quite small in early childhood.
A subcutaneous tough band covering the laryngeal mucosa extends from the cricoid cartilage to the thyroid cartilage and to the vocal processes of the
arytenoid cartilages. This is the cricothyroid membrane or ligament, the site of emergency cricothyroidostomy.
The surgical anatomy of the cricothyroid membrane was studied by Dover et al.,270 who emphasized the importance of knowledge of the pathway of the
cricothyroid artery (Fig. 1-88). They stated that in 93 percent of individuals, this artery arose from the superior thyroid artery; it crossed the upper one-half
of the cricothyroid membrane in 14 out of 15 cadavers. In cricothyroidostomy the severed cricothyroid artery, or anastomosing branches, may bleed unseen
directly into the trachea, with possible aspiration and death. The authors also identified several veins crossing the membrane. Their findings on the
dimensions of the cricothyroid membrane are seen in Figure 1-89.
Fig. 1-88.
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Cricothyroid artery (arrow) traversing upper portion of cricothyroid membrane. (Modified from Dover K, Howdieshell TR, Colborn GL. The dimensions and vascular
anatomy of the cricothyroid membrane: relevance to emergent surgical airway access. Clin Anat 1996;9:291-295; with permission.)
Fig. 1-89.
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Dimensions of cricothyroid membrane. Range and (mean) values reported in millimeters. (Modified from Dover K, Howdieshell TR, Colborn GL. The dimensions and
vascular anatomy of the cricothyroid membrane: relevance to emergent surgical airway access. Clin Anat 1996;9:291-295; with permission.)
Vascular Supply
Arteries
The chief sources of arterial blood to the trachea are the inferior thyroid arteries. At the tracheal bifurcation, these descending branches anastomose with
ascending branches of the bronchial arteries.
Veins
Small tracheal veins join the laryngeal vein or empty directly into the left inferior thyroid vein. The inferior thyroid veins arise as a venous plexus on the
anterior surface of the isthmus of the thyroid gland. Left and right descending veins enter the respective brachiocephalic veins (see Fig. 1-58). The two
veins may form a common trunk entering the superior vena cava or the left brachiocephalic vein.
Lymphatics
The pretracheal and paratracheal lymph nodes receive the lymphatic vessels from the trachea.
Innervation
The trachealis muscle and the tracheal mucosa receive fibers from the vagus nerve, recurrent laryngeal nerves, and sympathetic trunks. Small autonomic
ganglia are numerous in the tracheal wall.
HISTOLOGY AND PHYSIOLOGY
The histology and physiology of the trachea is covered briefly in the chapter on the respiratory system.
SURGERY OF THE TRACHEA
The following are the most common procedures performed on the trachea:
Tracheostomy
Resection of malignant tumors (primary or secondary) or benign tumors
Associated benign or malignant tracheal compression for tumors close to the trachea-related anatomic entities
Treatment of tracheal stenosis
Treatment of tracheoesophageal fistulas (multiple procedures, see chapter on esophagus).
Anatomic Landmarks and Relations
The usual site of a tracheostomy is between the 2nd and 4th or 3rd and 5th tracheal rings. Several structures are encountered.
Beneath the skin, the platysma lies in the superficial fascia and is absent in the midline. The anterior jugular veins may lie close to the midline; more
importantly, they may be united by a jugular venous arch at the level of the seventh to eighth tracheal rings in the suprasternal space of Burns.
The investing layer of deep cervical fascia is encountered when the superficial fascia is reflected. Deep to the investing fascia are the sternohyoid and
sternothyroid muscles. These muscles lie between the investing layer and the pretracheal fascia on either side of the midline. They are retracted laterally.
There are several structures within the visceral compartment under the pretracheal fascia. The isthmus of the thyroid gland commonly lies at the level of the
second and third tracheal rings; it is frequently more cranial, less frequently more caudal. The isthmus can be retracted upward or downward to reach the
trachea; if necessary, it can be ligated and incised. In about 10 percent of individuals, the two lobes of the thyroid are not connected by an isthmus.
The possibility of a thyroid ima artery should not be forgotten. A suspensory ligament of the thyroid (see "Deep Fascia: Pretracheal Layer" describing the
fasciae of the neck previously in this chapter) and a levator thyroid muscle may also be present in, or close to, the midline.
Indications for Tracheostomy
Tracheostomy is performed following extensive operative procedures upon the neck when postoperative laryngeal edema exists, or as a concurrent procedure
when a total laryngectomy is performed, or following severe facial trauma. It may also be performed as an emergency procedure to establish an airway when
there is obstruction by a foreign body, laryngeal edema or postoperative vocal cord paralysis. It can be performed either above or below the isthmus of the
thyroid gland, although the lower approach is usually preferable. The isthmus can be retracted superiorly or divided between hemostats.
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thyroid gland, although the lower approach is usually preferable. The isthmus can be retracted superiorly or divided between hemostats.
A hook is usually placed beneath the cricoid cartilage in the midline to stabilize the trachea and pull it forward. The incision in the trachea can be performed
either in vertical or horizontal fashion; usually, however, the 3rd, 4th, and 5th tracheal rings are divided vertically from above downward. Today, the majority
of surgeons take a window out of the 2nd or 3rd ring. The incision is held open for insertion of the tracheostomy tube. It is important to select a tube of the
proper size so that pressure of the tube will not cause necrosis of the posterior tracheal wall.
After evaluating tracheostomy in 76 pediatric burn patients (newborn to three years of age), Coln et al.271 concluded that pediatric tracheostomy may be
performed safely without complications and with acceptable chronic morbidity.
When emergency tracheostomy is indicated, the procedure of choice is cricothyroidostomy. The procedure is very simple. After laryngeal stabilization, the
skin and subcutaneous tissue are incised by a short vertical incision. The membrane is palpated and incised transversely, then dilated. The tracheostomy
tube is inserted.
Maipang et al.272 performed mediastinal tracheostomies in 12 patients with advanced carcinoma of the lower neck and superior mediastinum.
ANATOMIC COMPLICATIONS
Tracheostomy
General Precautions
Ger and Evans273 related the anatomic complications of tracheostomy to the age of the patient and the location of the stoma. Neonates and infants have
more complications. The same authors described the complications that occur when tracheostomy is performed above or below the isthmus. The anatomic
landmark is the 1st tracheal ring, which is identified below the lower border of the cricoid cartilage and above the upper border of the isthmus. Of course, this
depends upon the thickness and width of the isthmus.
The space between the isthmus and the suprasternal notch is at the level of the 2nd or 3rd tracheal rings above and the 4th or 5th tracheal rings below.
High tracheostomy can produce tracheal stenosis; lower tracheostomy can also produce a galaxy of anatomic complications in adults and children.
Read an Editorial Comment
Remember
The brachiocephalic artery in adults lies anterolaterally to the right of the trachea and very close to the tracheal stoma. Fatal bleeding from injury was reported by
Silen and Spieker,274 Yang et al.,275 and Takano.276
Know the location of the left brachiocephalic vein. In children, the vein is located at the lowest part of the neck, just above the manubrium. In adults, it is located
behind the sternum at the upper half of the manubrium.
Inferior thyroid veins and the thyroid ima artery are located at the anterior wall of the trachea. They should be ligated to avoid bleeding.
Division of the thyroid isthmus is a good technique for avoiding complications.
Combined injuries of the trachea and esophagus should be repaired primarily. The sternocleidomastoid muscle can be used between the two repaired organs.277
Upadhyay et al.278 reported that tracheostomy can safely be performed without transporting the patient to the operating room. Their study of 470 patients showed
no significant difference in complications between the 311 patients (8.7%) who underwent bedside tracheostomy and the 159 patients (9.4%) who underwent
operating room tracheostomy.
If a drain is used, it should be brought out through a stab wound on the opposite side of the neck.
Vascular Injury
The following alerts you to several vessels that may bleed during tracheostomy.279
The anterior jugular veins may be encountered as the investing fascia is incised.
The venous thyroid plexus over the thyroid gland drains into the thyroid veins. The inferior thyroid veins drain inferiorly into the brachiocephalic veins, either forming
a single stem or draining separately. The inferior thyroid vein is often asymmetric, hence, more liable to injury.
The branches of the superior and inferior thyroid arteries may anastomose across the midline.
A thyroid ima artery is very occasionally present, and must be ligated if found.
The brachiocephalic artery and left brachiocephalic vein can be injured if sharp dissection is carried too far downward. The artery can be eroded by a tracheostomy
tube, resulting in a tracheoarterial fistula.
The subclavian artery and vein can be compromised by a tracheostomy tube that is incorrectly curved or placed too low (Fig. 1-90).
The common carotid artery can be injured when attempting a tracheostomy in the newborn. Moreover, it has been mistaken for the trachea. The left common carotid
artery may arise from the brachiocephalic trunk, thereafter crossing the lower part of the cervical trachea.
Fig. 1-90.
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Tracheostomy tubes: A, Tube too curved. The tracheal wall may be eroded and the subclavian artery may be occluded. B. Tube placed too low. Subclavian vessel
may be occluded. C, Tube with correct curvature correctly placed. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery.
New York: McGraw-Hill, 1983; with permission.)
Organ Injury
ESOPHAGUS
Injury to the esophagus usually occurs not from errors of perception of the anatomy, but from errors in the use of the tracheostomy tube. It is possible,
however, to create an iatrogenic tracheoesophageal fistula by careless manipulation.280
PNEUMOTHORAX AND PNEUMOMEDIASTINUM
Pneumothorax and pneumomediastinum also have been reported.
RECURRENT LARYNGEAL NERVES
Injury to these nerves can occur during tracheostomy as well as during thyroidectomy (see "Anatomic Complications of Thyroidectomy").
LARYNX
Too high a tracheostomy can result in direct injury to the vocal cords. Placement of the tube through the thyrohyoid membrane can also produce vocal cord
injury.279 The stoma should be formed below the first ring.
POSTTRACHEOSTOMY SWALLOWING DYSFUNCTION
The adverse effect of a cuffed tracheostomy tube on the swallowing mechanism was studied by Bonanno.281 Evaluation of the maxillary, glossopharyngeal,
recurrent, and external laryngeal nerves revealed that nerve injury was not a factor. Bonanno concluded that the dysfunction was produced by inhibition of
elevation and anterior rotation of the larynx and by failure of the hypopharyngeal sphincter to open completely.
Inadequate Procedures
An appreciation of the angle of the trachea to the surface of the neck is important in selecting a tube with the proper curvature. The distal end of a tube
with too much curvature will erode the anterior tracheal wall.185 Roe282 recommended a 60-degree curvature (Fig. 1-90).
Cricothyroidostomy
The anatomic complications of cricothyroidostomy are as follows:
Bleeding
Pneumomediastinum
Subcutaneous emphysema
Change of voice
Paresis of the vocal fold
Laryngeal fracture
Dysphonia
Subglottic stenosis
SALIVARY GLANDS
INTRODUCTION
The major salivary glands (parotid, submandibular, and sublingual) are shown in Fig. 1-91.
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The major salivary glands (parotid, submandibular, and sublingual) are shown in Fig. 1-91.
Fig. 1-91.
Salivary glands and their ducts. Dissection showing the sublingual, submandibular (submaxillary), and parotid glands. Deep lateral view of the lingual region with the
body and part of the ramus of the mandible cut away to expose the glands and related structures. (Modified from Anson BJ (ed). Morris' Human Anatomy (12th ed).
New York: McGraw-Hill, 1966; with permission.)
Salivary choristomas, hamartomas, embryonic rests, and displaced surface glands within alveolar bone may develop into intraosseous salivary neoplasms.283
Ha et al.2 reported an unusual salivary gland choristoma in the middle ear space which appeared to be a developmental abnormality associated with
abnormalities of adjacent structures.
Parotid Glands
EMBRYOGENESIS
Normal Development
Early in the sixth week of development, the parotid duct appears as a solid outgrowth of the oral epithelium. It grows posteriorly, toward the ear, investing
the facial nerve (VII) with its branches. The solid cords subsequently become canalized, and the cells at the tips of the branches differentiate into secretory
acini.
Congenital Anomalies
Congenital absence of major salivary glands is rare. Martinez Subias et al.285 reported total agenesis of the parotid gland.
Accessory glandular tissue separated from the main gland is not rare. Parotid tissue may extend forward between the two pterygoid muscles ("pterygoid
lobe") and upon the masseter muscle ("accessory lobe"), and occasionally forms even more medially on the buccinator muscle.
We agree with Anson and McVay286 that accessory tissue is common (20%). Most common is a local aggregation of glandular tissue (the "socia parotis")
along the parotid duct, into which the small ducts of the accessory tissue empty. These accessory parotid tissues have their own blood supply from the
transverse facial artery.
SURGICAL ANATOMY
General Relations
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The parotid gland lies beneath the skin, in front of and below the ear. It is contained within the investing layer of the deep fascia of the neck, called the
parotid fascia. It is separated from the submandibular gland by a fascial thickening, the stylomandibular ligament.
The parotid gland occupies the parotid space, the boundaries of which are:
Anterior: Masseter muscle, ramus of the mandible, and medial pterygoid muscle
Posterior: Mastoid process, sternocleidomastoid muscle, and posterior belly of the digastric muscle and facial nerve
Superior: External auditory meatus, and temporomandibular joint
Inferior: Sternocleidomastoid muscle, and posterior belly of the digastric muscle
Lateral: Investing layer of the deep cervical fascia, skin, and platysma muscle
Medial: Investing layer of the deep cervical fascia, styloid process, internal jugular vein, internal carotid artery, and pharyngeal wall
From the anterolateral edge of the gland, the parotid duct (Stensen's) passes lateral to the masseter muscle. It turns medial at the anterior margin of the
muscle, where it is related to the buccal fat pad or "boule de Bichat" (Fig. 1-92). The buccal pad is located medial to the parotid duct, between the masseter
and buccinator muscles.287 The buccinator muscle is pierced by the duct. It enters the oral cavity at the level of the upper second molar tooth. Accessory
parotid tissue may extend along the parotid duct. A short accessory duct may enter the main duct.286,287
Fig. 1-92.
The anatomic relations of the buccal pad of fat. (Modified from Tostevin PMJ, Ellis H. The buccal pad of fat: a review. Clin Anat 1995;8:403; with permission.)
Some authors41,77 described three surfaces (lateral, anterior, and posterior), three borders (anterior, medial, and superior), and two extremities (superior or
base, and inferior or apex).
There has long been controversy about the lobes of the parotid gland. Two important studies, which both appeared in 1956, illustrate the problem. Davis and
coworkers288 concluded that there is a superficial lobe and a deep lobe of the gland; the branches of the facial nerve run between them. In contrast,
Winsten and Ward289 visualized the gland as essentially unilobar; the branches of the facial nerve are "intimately enmeshed within the gland tissue," with no
cleavage plane between the nerve and gland. Beahrs23 agreed with the unilobar concept, as did Hollinshead.36 The view that one accepts does not change
the surgical procedure of superficial parotidectomy.
Poncet et al.290 stated that the surgical division of the parotid gland into 3 parts, or "lobes," in relation to the facial nerve is a practical custom. We have
seen one lobe, or two lobes (superficial and deep). We think that the so-called third or fourth lobes are nothing but embryologic parotid segments.
Parotid Fascia
The parotid fascia is the splitting of the general investing layer that envelops both the parotid and submandibular (submaxillary) glands, forming the superficial
and deep layers. The superficial layer is dense and tough in comparison to the deep, which is thin and weak. However, the stylomandibular ligament between
the styloid process and the angle of the mandible is derived from the deep layer. It is tough, and separates the parotid from the submandibular gland.
The parotid space communicates medially with the lateral pharyngeal space and with the posterior area of the masticator space. The posterior area of the
masticator space contains the masseter muscle, the pterygoid muscles, the small pterygomandibular space and the space of the body of the mandible.
Since many intraparotid anatomic entities radiate from the gland, the surgeon should be familiar with all of them, especially those that must not be sacrificed.
Bed of the Parotid Gland
Complete removal of the parotid gland reveals the following structures (the acronym VANS may be helpful in remembering them):
One Vein: internal jugular
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Two Arteries: external and internal carotid
Four Nerves: glossopharyngeal (IX), vagus (X), spinal accessory (XI), hypoglossal (XII)
Four anatomic entities starting with "S": styloid process, and styloglossus, stylopharyngeus, and stylohyoid muscles.
The topography of VANS is as follows:
The internal jugular vein is located medial to the styloid process, positioned posteriorly.
Occasionally the external carotid artery is embedded within the deep lobe, but usually it is superficial.
The internal carotid artery can be found anterior to the internal jugular vein.
The styloid process in adults is approximately 2.5 cm long and its tip is located between the external and internal carotid arteries, just lateral to the tonsillar fossa.
An elongated styloid process (called Eagle's syndrome because Eagle described it in 1937) can cause throat, neck, or facial pain.
The glossopharyngeal nerve (IX) snakes around the stylopharyngeus muscle, spiraling around its posterior surface as it passes inferiorly and medially to the wall of
the pharynx.
The vagus nerve (X) is located under or, occasionally, between the internal jugular vein and the internal carotid artery. The origin of the superior laryngeal branch is
found in this vicinity.
The spinal accessory nerve (XI) is superficial and lateral to the carotid sheath.
The hypoglossal nerve (XII) is located superficial and medial to the carotid sheath.
In addition to the styloid process are the muscles beginning with "S": the styloglossus and stylopharyngeus, which are beneath the external carotid artery, and the
stylohyoid, which is above it.
Vascular Supply
Arteries
The external carotid artery (Fig. 1-93) enters the inferior surface of the gland and divides at the level of the neck of the mandible into the maxillary and
superficial temporal arteries. The latter gives rise to the transverse facial artery. Each of these branches emerges separately from the superior or anterior
surface of the parotid gland.
Fig. 1-93.
Diagrammatic representation of the relationship of the parotid gland to the branches of the external carotid artery. (Modified from Skandalakis JE, Gray SW, Rowe JS
Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
NOTE: An artery which has nothing to do with the parotid is the middle meningeal artery: it is a branch of the maxillary artery which arises slightly anterior to
the neck of the mandible in the infratemporal fossa. It enters the cranial cavity through the foramen spinosum and supplies blood to the dura mater within
the skull.
Veins
The superficial temporal vein (Fig. 1-94) enters the superior surface of the parotid gland. It receives the maxillary vein to become the retromandibular vein.
Still within the gland, the retromandibular vein divides. The posterior branch joins the posterior auricular vein to form the external jugular vein. The anterior
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Still within the gland, the retromandibular vein divides. The posterior branch joins the posterior auricular vein to form the external jugular vein. The anterior
branch emerges from the gland to join with the facial vein, thereby forming the common facial vein, a tributary to the internal jugular. Remember: the facial
nerve is superficial, the artery is deep, and the retromandibular vein lies between them.
Fig. 1-94.
Diagrammatic representation of the relationship of the parotid gland to tributaries of the external and internal jugular veins. (Modified from Skandalakis JE, Gray SW,
Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Lymphatics
The preauricular lymph nodes in the superficial fascia drain the temporal area of the scalp, upper face, lateral portions of the eyelids, and anterior pinna.
Parotid nodes within the gland drain the gland itself, as well as the nasopharynx, nose, palate, middle ear, and external auditory meatus. These nodes, in
turn, send lymph to the subparotid nodes and eventually to the nodes of the internal jugular vein and spinal accessory chains (see Table 1-2).
Marks291 discussed the number of lymph nodes in the parotid area. He reported finding 1 to 11 lymph nodes in 17 specimens of radical parotidectomy. His
opinion is that perhaps a significant number may be left in the skin flaps.
Innervation
Autonomic Nervous System
The parotid gland is innervated by the parasympathetic and sympathetic divisions of the autonomic nervous system.
The parasympathetic innervation of the parotid gland originates from the glossopharyngeal nerve. Its tympanic branch (the nerve of Jacobson) ascends into
the skull through a small tympanic canaliculus to reach the middle ear, where it enters into the formation of a nerve plexus on the promontory of the medial
wall of the middle ear cavity. This plexus consists of a mixture of sensory (pain) and autonomic fibers. The lesser (superficial) petrosal nerve (Fig. 1-95),
consisting of presynaptic parasympathetic neurons, emerges from this plexus, leaves the middle ear cavity, travels across the floor of the middle cranial
fossa, and then descends through the foramen ovale to reach the otic ganglion. The otic ganglion is suspended from the mandibular nerve, just inferior to the
foramen ovale. The presynaptic parasympathetic fibers of the lesser petrosal nerve synapse upon the neurons within the otic ganglion. The postsynaptic
parasympathetic fibers leave the ganglion, forming one of the two roots of the auriculotemporal nerve, which pass on either side of the middle meningeal
artery, near the foramen spinosum. Several branches of the auriculotemporal nerve pass into the parotid, carrying postsynaptic parasympathetic fibers to the
glandular units. Some of these fibers are delivered to the secretory units by branches of the facial nerve as it passes through the gland. The
parasympathetic fibers are secretomotor; when stimulated by sensory (or psychic) stimuli, these fibers elicit profuse, watery secretion of the gland (Fig. 196). Last 292 has a beautiful and pragmatic expression in which he stated that the secretomotor fibers reach the gland by "hitchhiking."
Fig. 1-95.
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Schema of the parasympathetic innervation of the parotid gland. Solid line, preganglionic pathway. Broken line, postganglionic pathway.
Fig. 1-96.
Secretomotor nerve to parotid gland. (Modified from Basmajian JV, Slonecker CE. Grant's Method of Anatomy [11th ed]. Baltimore: Williams & Wilkins, 1989; with
permission.)
The sympathetic supply to the parotid originates from spinal cord segments T1-T3 (Fig. 1-97). Fibers follow the vertebral roots of the three upper thoracic
nerves, then travel via white rami communicantes to the upper sympathetic thoracic trunk and upward to the cervical sympathetic, reaching the superior
cervical ganglion. From this, branches travel toward the external carotid artery forming a sympathetic plexus, whose fibers follow the branches of the
external carotid to reach the parotid gland. The primary function of the sympathetic system may be vasoconstriction.
Fig. 1-97.
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Sympathetic supply to the parotid gland. WRC, white rami communicantes.
Auriculotemporal Nerve
The auriculotemporal nerve, a branch of the mandibular division of the trigeminal cranial nerve, carries postganglionic parasympathetic fibers to the parotid
gland. The preganglionic parasympathetic fibers for the parotid are carried initially by the glossopharyngeal nerve and its lesser petrosal branch; the
postganglionics arise in the otic ganglion, just outside the skull, deep to the main stem of the mandibular division of the trigeminal nerve. In addition, the
auriculotemporal nerve is sensory to the external ear and ear canal, temporomandibular joint, and skin of the temporal part of the face. It traverses the upper
part of the parotid gland and emerges with the superficial temporal blood vessels from the superior surface of the gland (Fig. 1-98).
Fig. 1-98.
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Diagrammatic representation of the relations of the parotid gland to the facial nerve and its branches. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr.
Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Within the gland, the auriculotemporal nerve communicates with the facial nerve. The auriculotemporal nerve is, for all practical purposes, sensory and
secretory.
Usually the order of the structures from the tragus anteriorly is: the auriculotemporal nerve, superficial temporal artery and vein, and temporal branch of the
facial nerve.
Related Nerves
Two nerves that are related to the parotid gland, but do not innervate it, are the facial nerve and the great auricular nerve.
FACIAL NERVE
The facial nerve has nothing to do with parotid innervation, but we present the nerve here because of its very close relationship with the parotid and salivary
glands.
The main trunk of the facial nerve (Fig. 1-98) enters the posterior surface of the parotid gland about 1 cm from its emergence from the skull through the
stylomastoid foramen, about midway between the angle of the mandible and the cartilaginous ear canal.
It is important to remember that at birth the child has no mastoid process; the stylomastoid foramen is subcutaneous. Therefore, the facial nerve's position
makes it particularly vulnerable.
About 1 cm from its entrance into the gland, the facial nerve typically divides to form five branches: temporal, zygomatic, buccal, mandibular, and cervical.
In most individuals, an initial bifurcation called the pes anserinus forms an upper temporofacial and a lower cervicofacial division, but six major patterns of
branching, based on a series of simple to complex arrangements, have been distinguished.288
In general, the nerve and its branches lie in a plane dividing the deep and superficial portions of the gland, but there is no true fascial plane between these
portions.
Beahrs23 suggested the following method to identify the facial nerve: The lower tip of the mastoid process is palpated and a fingertip is placed on the lateral
surface pointing forward. The trunk of the facial nerve will be found deep and anterior to the center of the fingertip.
The easiest method of identification takes a lateral approach. The insertion of the posterior belly of the digastric muscle is identified. The nerve is just medial
to the insertion point.
The styloid process is an unreliable landmark because of variations in its shape and size. Other landmarks for locating the facial nerve have been suggested,
e.g., the external auditory canal293 and the tympanomastoid suture.294,295
GREAT AURICULAR NERVE
The great auricular nerve arises from the second and third nerves of the cervical plexus. It reaches the posterior border of the sternocleidomastoid muscle
near the junction of the upper third and lower two-thirds of the muscle (Erb's point). Thereafter it passes obliquely upward and forward to the interval
between the earlobe and the angle of the mandible, roughly following the course of the external jugular vein (Fig. 1-98). It is usually sacrificed at
parotidectomy. Numbness in the preauricular region, the lower auricle, and the lobe of the ear results from injury to this nerve, but disappears after 4 to 6
months.
In summary, the branches of the facial nerve may be approximated by a radiating series of lines, each of which begins at the intertragic notch of the external
ear (Fig. 1-99):
Temporal branch: from notch to point "A" halfway between ear and lateral angle of the eye
Zygomatic branch: from notch to lateral angle of eye
Buccal branch: from notch to .5 cm above the labial tubercle of the upper lip
Cervical branch: from notch to a point ("B") halfway between the ear lobe and the angle of the mandible
Marginal mandibular: from notch to a point about 1 cm below the vascular notch of the mandible
Fig. 1-99.
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Superficial distribution of the facial nerve. Schematic representation of the typical positions of the branches of the facial nerve in relation to visible or palpable
topographic features of the face. A, indicates the midpoint of a line between the lateral angle of the eye and the anterior surface of the ear. A line from the
intertragic notch as shown will overlie the temporal branch. B, indicates the midpoint of a horizontal line drawn from the angle of the mandible to just below the lobe
of the ear. A line drawn from the intertragic notch to this midpoint overlies the typical course of the cervical branch.
The great auricular nerve may be used as a nerve graft.
SURGERY OF THE PAROTID GLAND
An inflammatory process of the parotid produces severe pain because of the tough unyielding superficial parotid fascia, which triggers pain fibers carried by the
auriculotemporal nerve. Since the parotid tissue extends into the retromandibular area, any movement of the jaw will produce severe pain. Remember the probable
cause of parotiditis (the 4 D's): debility, dehydration, depressed salivation, and dirty mouth.
Abscesses may be formed secondary to pharyngeal perforation or blood-borne infections. Stone formation within the duct and obstruction is another etiology of
abscess formation. The stone may be palpated (if large enough) within the mouth. The yielding deep parotid fascia may rupture; pus will travel to the retromandibular
space, temporomandibular joint, or external auditory canal. This abscess can be drained through the oral cavity or occasionally by a vertical incision of the skin and
elevation of the gland.
Chronic sclerosing sialadenitis, a chronic inflammatory condition of the salivary glands (especially the submandibular gland) which cannot be clinically distinguished
from a true neoplasm, is also known as Kuttner tumor. Williams et al.296 reported a case of Kuttner tumor of the submandibular and parotid glands exhibiting
widespread swelling.
Tunkel et al.297 stated that HIV infection has broad manifestations affecting the head and neck, and reported 5 seropositive patients with bilateral parotid
enlargement.
Parotid tumors may be benign or malignant. Most of the benign tumors are located in the superficial lobe and should be excised not by enucleation, but by
lobectomy. Malignant tumors should be treated by total parotidectomy; sacrifice the facial nerve if it is involved with the process.
We quote from James and Sharma 298 on parotid gland sarcoidosis:
Parotid gland sarcoidosis occurs in 6% of patients with sarcoidosis. It was bilateral in 24 (73%), slightly commoner in women, and presented in the
majority in the 20 to 40 year age group. There was widespread involvement of other systems, particularly intrathoracic, peripheral lymphadenopathy,
uveitis, lacrimal gland enlargement and skin disease. Patterns of involvement may be pathognomic as in Heerfordt's disease.
In patients with carcinoma of the parotid gland, Kelley et al.299 advise neck dissection only for those histologic diagnoses that carry the highest risk of nodal
metastases and for those patients whose primary tumor resection might be facilitated by lymphadenectomy. In other words, neck dissection should be performed
only when there are clinically enlarged nodes or when CT scan gives evidence of nodal involvement.
Renehan et al.300 analyzed treatment of patients with recurrent pleomorphic adenoma of the parotid gland. Those with multinodular recurrences are at high risk of
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relapse; they benefit from surgery with radiotherapy. Patients with uninodular recurrences may be adequately treated by surgery alone. A rare pleomorphic salivary
adenoma in an adolescent was reported by Forty and Wake.301
The syndrome of Frey (auriculotemporal nerve syndrome) consists of gustatory sweating and flushing of the ipsilateral face following parotidectomy, penetrating
wounds, or infection of the parotid. This condition may be caused by stimulation of the preauricular sweat glands. Irregular regeneration in the distribution of
auriculotemporal nerve fibers causes flushing and sweating to take place when eating, tasting, or smelling. The treatment of Frey's syndrome is section of the
glossopharyngeal nerve, which supplies the preganglionic fibers for the parotid gland.
Trauma in the parotid area can produce injury of the facial nerve or division of the parotid duct. Microsurgery is the procedure of choice for both. If this is not
possible for the duct, proximal and distal ligation is acceptable. For a salivary fistula, radiation may be indicated to produce atrophy of the gland.
A graft can be used for the facial nerve, employing the following nerves for donor tissue segments: the greater auricular, ilioinguinal, lateral femoral
cutaneous, and sural. The great auricular is the best because it is located in the same area and because its caliber is almost the same as that of the facial
nerve.
Remember that the facial nerve is superficial, a vein is under the nerve, and the artery is deepest.
Most of the tumors of the parotid are benign; most of the tumors of all the minor salivary glands are malignant.302 Why this is so is not known.
The most common procedure for a benign tumor is removal of the parotid lobe. Enucleation of the tumor is very tempting, but it is the wrong procedure because of
its high recurrence rate. Total parotidectomy for malignant tumors is the treatment of choice despite possible sacrifice of the facial nerve. With inflammatory process
and abscess formation an anatomic incision for draining is advised.
North et al.303 demonstrated the efficacy of postoperative irradiation for improving survival and local control in patients with carcinomas of the parotid and
submandibular glands.
In a review of pediatric neoplasms of the major salivary glands, Shikhani and Johns 304 recommended complete removal of the tumor at initial surgery (Tables 1-13,
1-14, and 1-15).
We strongly advise the surgeon interested in treatment of parotid and salivary cancers to study works of Johns and colleagues.305-308
Table 1-13. Benign Salivary Gland Neoplasms in Children (229 from Literature, 18 from Johns Hopkins)
Histology
Number
Percent
Pleomorphic adenoma
214
86.6
Plexiform neurofibroma
8
3.2
Warthin's tumor
5
2
Cystadenoma
5
2
Lymphoepithelial lesion
3
1.2
Neurilemmoma
3
1.2
Embryoma
3
1.2
Xanthoma
2
0.8
Adenoma
1
0.4
Total
247
100%
Source: Shikhani AH, Johns ME. Tumors of the major salivary glands in children. Head Neck Surg 1988;10:257-263; with permission.
Table 1-14. Malignant Salivary Gland Neoplasms in Children (243 from Literature, 3 from Johns Hopkins)
Histology
Number
Percent
Mucoepidermoid carcinoma
122
49.6
Acinic cell carcinoma
30
12.2
Undifferentiated carcinoma
22
8.9
Adenoid cystic carcinoma
16
6.5
Adenocarcinoma
19
7.7
Malignant mixed tumor
10
4.1
Rhabdomyosarcoma
6
2.4
Undifferentiated sarcoma
5
2.0
Mesenchymal sarcoma
5
2.0
Unclassified carcinoma
4
1.6
Squamous cell carcinoma
3
1.2
Lymphoma
3
1.2
Ganglioneuroblastoma
1
0.4
Total
246
100%
Source: Shikhani AH, Johns ME. Tumors of the major salivary glands in children. Head Neck Surg 1988;10:257-263; with permission.
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Table 1-15. Summary of Treatment and Outcome of 272 Cases in Childhood Salivary Gland Neoplasms
Histology
Initital Treatment
No. of Cases Recurrence NED (%)
DOD Follow-Up
Pleomorphic adenoma (parotid)
Superior parotidectomy
41
8 (19.5)
23/25 (92)
0
1-29 yrs
Total parotidectomy
14
1 (7.1)
14/14 (100) 0
4-22 yrs
Excision
56
22 (39.3)
45/50 (90)
1
1-49 yrs
Pleomorphic adenoma (submandibular)
Excision
21
4 (19)
21/21 (100) 0
3-25 yrs
Mucoepidermoid carcinoma (parotid)
Superior parotidectomy
13
4 (30.7)
11/11 (100) 0
2-17 yrs
Total parotidectomy
7
0 (0)
7/7 (100)
0.5-22 yrs
Excision
41
20 (48.8)
16/17 (94.1) 1
1-14 yrs
Excision & RT
5
0 (0)
5/5 (100)
0
1-5 yrs
Mucoepidermoid carcinoma (submandibular) Excision & RT
2
1 (50)
2/2 (100)
0
5.5 & 7 yrs
Acinic cell carcinoma (parotid)
Superior parotidectomy
1
0 (0)
1/1 (100)
Total parotidectomy
2
0 (0)
2/2 (100)
0
2 & 3 yrs
Excision
19
5 (26)
6/7 (85.7)
0
2-16 yrs
Superior parotidectomy
2
0 (0)
2/2 (100)
0
0.5 & 10 yrs
Total parotidectomy
4
2 (50)
2/4 (50)
2/4
0.5-18 yrs
Excision
9
5 (55.5)
3/7 (42.8)
4/7
10-51 yrs
Total parotidectomy
2
Adenoid cystic carcinoma (parotid)
Miscellaneous carcinoma*
Sarcoma (parotid)
0
4 yrs
1 (50)
1 (50)
1/2
2 mos-7 yrs
Total parotidectomy & RT 3
1 (33.3)
2/3 (66.6)
1/3
2-14 yrs
Excision
10
8 (80)
1/8 (12.5)
7/9
9 mos-8 yrs
Excision & RT
8
7 (87.5)
1/6 (16.6)
5/6
3-9 mos
RT alone
2
2 (100)
0 (0)
2/2
4-12 mos
Total parotidectomy
3
1 (33.3)
2/3 (66.6)
1/3
7-22 yrs
Total parotidectomy & RT 3
3 (100)
0
3
0.3-3 yrs
Excision & RT
3
3 (100)
0
3
6-8 mos
RT alone
1
1 (100)
0
1
15 mos
*Miscellaneous carcinomas undifferentiated, adeno, malignant mixed, and unclassified carcinoma
NED, no evidence of disease; DOD, dead of disease; RT, radiation therapy.
Source: Shikhani AH, Johns ME. Tumors of the major salivary glands in children. Head Neck Surg 1988;10:257-263; with permission.
ANATOMIC COMPLICATIONS
Vascular Injury
The major vessels crossing the parotid bed must be divided and ligated during parotidectomy. Bleeding from small vessels can result in hematoma.
Nerve Injury
The most commonly injured branches of the facial nerve are the buccal and mandibular; they also have few interconnections with other branches. The facial
nerve and its branches are obviously in danger during parotidectomy. They can be preserved only by careful observation and awareness of the previously
described anatomy. A stimulating electrode can be employed in verifying facial motor branches, causing muscle spasms when a nerve is contacted. The facial
trunk is large enough for anastomosis of the cut end, should this be necessary. A large cutaneous nerve of the calf (sural nerve) is often used in this
procedure to graft to the contralateral intact nerve. The smaller branches are injured more often and are much less easily sutured. No repair will completely
restore function. A traction injury may result in temporary paresis or permanent injury.
Brenner and Schoeller309 reported that the masseteric nerve, a branch of the mandibular nerve (Fig. 1-100), is a possible donor for facial nerve anastomosis
to restore function (closure of the mouth and eye) following facial nerve paralysis. Spira310 was perhaps the first to anastomose the masseteric nerve to the
facial nerve. The masseter muscle is denervated but its function, according to Brenner and Schoeller,309 may be taken over by the temporal muscle. Other
nerves used to restore facial nerve function are the hypoglossal, spinal accessory, and glossopharyngeal nerves.
Fig. 1-100.
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Diagram of the mandibular nerve in the region deep to the ramus of the mandible. In this lateral view the otic ganglion, situated on the medial side of the mandibular
nerve, is indicated in outline. The branch of the mandibular to the tensor veli palatini, which passes medially through the otic ganglion, is not shown. (Modified from
Hollinshead WH. Anatomy for Surgeons (2nd ed): Vol.1, The Head and Neck. New York: Harper & Row, 1968; with permission.)
Fournier et al.311 reported that the motor distribution of the mandibular nerve makes it a possibility for a masseteric-facial anastomosis to restore facial
function. They wrote, "The modest results and the side effects of the facio-hypoglossal anastomosis used for facial rehabilitation have led us to consider an
anastomosis between a motor branch of the trigeminal nerve and the facial nerve. Dissection has allowed us to demonstrate that the masseteric nerve offers
the characteristics and the relationships which should make such an anastomosis feasible."
Injury to the auriculotemporal nerve can produce Frey's syndrome, in which the skin anterior to the ear sweats during eating ("gustatory sweating";
considered previously under "Surgery of the Parotid Gland").
Submandibular Glands
EMBRYOGENESIS
The submandibular glands appear at approximately the end of the 6th week. The endoderm and oral epithelium in the floor of the primitive oral cavity are
responsible for the genesis of these glands. They are located lateral to the primitive tongue. Acini are formed around the 12th week. According to
Sperber,312 the glands also begin secreting at this time. The submandibular duct is formed later by the closure of a linear groove.
SURGICAL ANATOMY
The superficial portion of the submandibular gland is about 4 cm long, lying in the submandibular triangle superficial to the mylohyoid muscle. A tongue of
glandular tissue passes deep to the muscle, enveloping its posterior border to form the much smaller deep portion of the gland (see Fig. 1-18).
Important relationships of the superficial portion are: (1) the inferior surface is related to the facial vein and the cervicofacial branches of the facial nerve,
including the marginal mandibular and cervical rami; (2) the lateral surface is related to the facial artery; and (3) the medial surface is related to the
glossopharyngeal, lingual, and hypoglossal nerves.
The deep portion of the submandibular gland is related to the lingual nerve and submandibular ganglion above, and the hypoglossal nerve below (see Fig. 119).
The submandibular (Wharton's) duct emerges from the middle of the deep portion of the gland, crosses the sublingual space, and opens into the mouth on
the side of the frenulum of the tongue. Proximally it lies between the mylohyoid and hyoglossus muscles; distally it lies between the genioglossus muscle and
the sublingual gland.
The lingual nerve, a branch of the mandibular division of the trigeminal nerve (V), has a special relationship to the duct.25 The nerve lies first above and then
lateral to the duct, crossing below and then medial to it (see Fig. 1-19). The danger of injuring the nerve when sectioning the duct is obvious. The
hypoglossal nerve must also be protected inferior to the duct.
Marginal Mandibular Nerve
In about 50 percent of subjects, the mandibular branch of the facial nerve (marginal mandibular nerve) lies beneath the lower margin of the mandible. In the
remainder it lies below the mandible, posterior to the crossing of the facial artery16 (see Fig. 1-15). Ziarah and Atkinson,313 after dissecting 110 facial
halves, also reported that in more than half of their specimens the mandibular branch ran below the mandible and distal to the facial vessels.
It is important to note that the mandibular nerve is multiple in about 80 percent of individuals.17
SURGERY OF THE SUBMANDIBULAR GLANDS
With malignant tumors, total excision is mandatory. Occasionally the lingual and hypoglossal nerves should be sacrificed. With inflammatory process, abscess
formation, or lithiasis a very anatomic incision is advised.
ANATOMIC COMPLICATIONS
Vascular Injury
The vessels most frequently injured during excision of the submandibular glands are the facial (external maxillary) artery and vein. Martin314 suggested that
the facial artery or vein be exposed, sectioned, and ligated well below the edge of the mandible. The distal stump of the vessel is then dissected upward with
upward traction so that the marginal mandibular nerve is carried upward by the loop of the vessel. The artery and vein can be sutured to the underside of
the skin flap. This procedure will ensure ligation of these vessels before they are sectioned inadvertently.
Nerve Injury
Marginal Mandibular Nerve: The procedure outlined above for avoidance of vascular injury completely protects the mandibular nerve from subsequent injury.
If the mandibular branch of the facial nerve is injured it results in a flattening of the lower lip on the affected side. If a nerve stimulator is used to identify the
nerve, the anterosuperior portion of the platysma may contract. Depression of the corner of the mouth may also be observed. Dingman and Grabb17
discussed this response.
Hypoglossal Nerve: See "Radical Neck Dissection" following in this chapter.
Lingual Nerve: See "Radical Neck Dissection."
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Sublingual Glands and Other Salivary Glands
EMBRYOGENESIS
The sublingual glands appear around the 8th week. They originate from several epithelial buds of endodermal origin which are located at the paralingual
sulcus. The buds form multiple ducts by canalization.
SURGICAL ANATOMY
The paired sublingual gland (Figs. 1-101, 1-102) is an amygdaloid (almond-shaped), flat and narrow gland, smaller than the other major salivary glands
(parotid and submandibular). The sublingual gland is located under the mucosae of the floor of the mouth. Its boundaries are:
Superior: mucosa of the oral floor
Inferior: mylohyoid muscle
Anterior: sublingual gland of the other side
Posterior: deep process (anterior prolongation) of the submandibular (submaxillary) gland; rarely, this may be affixed to a secondary inflammatory process
Medial: lingual nerve, submandibular duct, and genioglossus muscle
Lateral: medial surface of the lower mandible
Fig. 1-101.
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Superficial and deep structures in the sublingual region. ("Right" and "left" indicate the side of the drawing.) A, Superficial Structures. The mucosa is intact on the
left; on the right, the region has been cleared of the vessels and nerves. B, Deep Structures. The vessels and nerves have been removed on the left, and on the
right the vessels and nerves are in situ.
Fig. 1-102.
Lateral view of the sublingual region. The body of the mandible has been removed.
This mucous gland has multiple ducts: 10 to 30, according to O'Rahilly,315 and 8 to 20, according to Gray's Anatomy.54 The ducts drain directly into the oral
cavity on the sublingual fold, with some of them entering the submandibular duct.
SURGERY OF THE SUBLINGUAL GLANDS AND OTHER SALIVARY GLANDS
A calculus may form within the substance of the gland (sialolith). The calculus can be removed through a mucosal incision, or the gland in toto can be
removed. The danger zone is the medial boundary where the submandibular duct and lingual nerve are located.
Another pathologic condition is the formation of a cyst or mucocele, the well-known ranula. Origination of the ranula is usually in the sublingual glands or
minor salivary glands, although it can appear in the submandibular duct. Removal of the cyst or the cyst plus the sublingual gland is advisable if partial
removal of the roof is not successful.
It is not within the scope of this book to present all the salivary glands, especially the so-called minor salivary glands (lingual, labial, buccal, palatal, etc.).
These are located in the mucosa or submucosa of the oral cavity. They are ductless or have minute, very short ducts.
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Since most tumors developing in sublingual and other salivary glands are malignant, en bloc resection is advised. Johns et al.73 characterized salivary gland
carcinomas as "infrequent in any single surgeon's experience."
HISTOLOGY AND PHYSIOLOGY OF THE SALIVARY GLANDS
The histology of the parotid, submandibular, and sublingual glands is the same. Each of these glands is composed of parenchymal elements (lobules which
form lobes) and connective tissue.
The basic anatomic and physiologic unit is the salivon, which consists of acinar cells, myoepithelial cells covering the acinar cells, and a duct that provides
the pathway for the saliva.
The histochemistry and morphology of oncocytic and oncocytoid tumors of the salivary gland was studied by Johns et al.316 and Paulino and Huvos.317
BRANCHIAL REMNANTS
EMBRYOGENESIS
Between the fourth and sixth weeks of gestation, the embryonic foregut changes from a flattened tube into a complicated series of structures, some of
which represent the primordia of the respiratory apparatus of our aquatic vertebral ancestors. In mammals these structures become rearranged and adapted
to new functions, or they disappear, leaving only occasional vestiges (Table 1-16).
Table 1-16. Derivatives of Branchial Arches and Pouches
Branchial
Arch
Derivatives
Pouch and Cleft Aortic Arch
I (maxillary
and
mandibular)
1st (transitory)
Cranial Fleshy Structures
Nerve
Skeletal Structures
V
Dorsal: incus
Anterior two-thirds of tongue
Anomalous
Remnants
Ventral: malleus, Meckel's cartilage
I
(hyomandibular)
II (hyoid)
Dorsal: auditory canal, tympanic
membrane, middle ear, eustachian
tube
2nd (transitory)
VII
Ventral:
cervicoaural
fistula
Dorsal: stapes
Ventral: styloid process, stylohyoid
ligament, lesser horn of hyoid bone
II
III
Pharyngeal and palatine tonsils
3rd
IX
III
IV
4th (left aortic arch; right
brachiocephalic)
X
IV
Cysts,
sinuses, and
fistulas
Posterior third of tongue, lingual tonsil Ventral: greater horn of hyoid bone
Dorsal: inferior parathyroids
Cysts,
Ventral: thymus
sinuses (rare)
Epiglottis, base of tongue
Ventral: thyroid cartilage
Dorsal: superior parathyroids
Cysts?
Ventral: thymus
V
5th (transitory)
X
(Rare)
Ventral: cricoid, arytenoid cartilages
Ultimobranchial body (parafollicular
cells of thyroid)
VI
6th (proximal pulmonary
artery, distal ductus
arteriosus)
Cysts?
Tracheal cartilage
Source: Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.
In other sections of this chapter we have discussed structures adapted to new functions: the thyroid and parathyroid glands and the ultimobranchial bodies.
Here we are concerned with structures that normally disappear during embryonic life. These are the ectodermal clefts and the endodermal pouches of the
pharynx.
Of these gill-like organs, only the dorsal portion of the first cleft and first pouch persist —as the external auditory meatus from the former and the middle ear
and eustachian tube from the latter.
SURGICAL ANATOMY
Fistulas
Fistulas are patent ductlike structures that have both external and internal orifices.
Cervicoauricular fistulas extend from the skin at the angle of the jaw, and may open into the external auditory canal. These fistulas lie anterior to the facial
nerve. They are remnants of the ventral portion of the first branchial cleft (Fig. 1-103).
Fig. 1-103.
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Congenital cervicoaural fistula or cyst. This is a persistent remnant of the ventral portion of the first branchial cleft. The tract may or may not open into the external
auditory canal. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Lateral cervical fistulas almost always arise from the ventral portion of the second branchial cleft and pouch. They originate on the lower third of the neck on
the anterior border of the sternocleidomastoid muscle. The orifice may be pigmented. The path is upward through the platysma muscle and deep fascia.
Above the hyoid bone the track turns medially to pass beneath the stylohyoid and the posterior belly of the digastric muscle, in front of the hypoglossal
nerve, and between the external and internal carotid arteries. It enters the pharynx on the anterior surface of the upper half of the posterior pillar of the
fauces (Fig. 1-104A). It may open into the supratonsillar fossa or even into the tonsil itself.
Fig. 1-104.
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Track of a second pouch and cleft fistula passing from the tonsillar fossa of the palatine (faucial) tonsils to the neck. A, Complete fistula. B, External (cervical) and
internal (pharyngeal) sinuses. C, Cyst of branchial cleft origin lying in the carotid notch. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications
in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Sinuses
Internal sinuses are blindly ending spaces that extend outward from openings in the pharynx; external sinuses are blindly ending spaces that extend inward
from openings in the skin.
Internal sinuses are usually asymptomatic and, hence, undetected.318 External sinuses usually arise at the anterior border of the sternocleidomastoid muscle
and end in a cystic dilatation. Many such sinuses result from an infected cyst or previous incomplete excision of a cyst (Fig. 1-104B).
Cysts
Cysts are spherical or elongated spaces lying in the track of a branchial pouch or cleft and have no communication with the pharynx or skin.
Superficial cysts lie at the edge of the sternocleidomastoid muscle. Deeper cysts lie on the jugular vein or in the bifurcation of the carotid artery (Fig. 1104C). These are of branchial cleft origin and are lined with stratified squamous epithelium. Cysts on the pharyngeal wall deep to the carotid arteries are
usually of branchial cleft origin. They are lined with ciliated epithelium unless inflammatory or pressure changes have occurred (Fig. 1-105). Skandalakis and
Gray83 consider these embryonic structures in greater detail.
Fig. 1-105.
Incomplete closure of the second branchial cleft of the pouch may leave cysts: Type I, superficial, at the border of the sternocleidomastoid muscle. Type II, between
the muscle and the jugular vein. Type III, in the bifurcation of the carotid artery. Type IV, in the pharyngeal wall. Types I, II, and III are of second cleft origin; Type
IV is from the second pouch. M, sternocleidomastoid muscle; V, jugular vein; A, carotid artery. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical
Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
SURGERY OF THE BRANCHIAL REMNANTS
Surgery is the treatment of choice for all cysts, sinuses, and fistulas related to the branchial remnants.
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Branchial remnants originating in the piriform recess can cause recurrent fistulas or abscesses in the neck. Kim et al.319 recommend chemocauterization of
the internal opening to avoid recurrence from inadequate removal of the fistula tract.
ANATOMIC COMPLICATIONS
Vascular Injury
The external and internal carotid arteries just above the bifurcation of the common carotid artery are especially prone to injury while performing excision of
the branchial remnants, because a second cleft cyst or the path of a second cleft fistula will lie in the crotch of the bifurcation.
The following veins must be avoided or ligated during excision of the branchial remnants: the external jugular, anterior jugular, common facial, lingual, and
internal jugular.
Nerve Injury
A first cleft sinus or cyst passes over or under the facial nerve below and anterior to the ear. The cyst may displace the nerve either upward or downward.
When removing the cyst, the surgeon must be careful to protect the nerve.
Several nerves will be found above the pathway of a second cleft or pouch branchial fistula:
Mandibular branch of the facial nerve (protection of this nerve has been considered under "Submandibular Glands: Anatomic Complications")
Cervical branch of the facial nerve (the skin should be incised 4-5 cm below the mandibular angle)
Spinal accessory nerve (may be injured when trying to free a cyst or fistulous tract from the sternocleidomastoid muscle)
Descendens hypoglossi (superior root of the ansa cervicalis) (may be cut if necessary)
Hypoglossal nerve (the fistula crosses the nerve above the bifurcation of the common carotid artery)
Superior laryngeal nerves (see "Anatomic Complications of Thyroidectomy: Nerve Injury" for discussion of effects of injury)
Vagus nerve (lies parallel to the carotid artery [the fistula crosses the nerve near the level of the carotid bifurcation])
Organ Injury
The pharyngeal opening of a fistula or an internal sinus must be closed without producing a large iatrogenic defect. Remember that this is at or near the
tonsillar fossa. Uncontrolled bleeding can be a problem.
Inadequate Procedures
Drainage or aspiration of branchial cysts is useless, and will sooner or later result in infection. Removal of all epithelial tissue is the only cure.
RADICAL NECK DISSECTION
INTRODUCTION
A radical neck dissection involves complete excision of the primary lesion, together with all nonessential structures and their lymph nodes, collecting lymph
trunks, fascia, and fat. By definition radical neck dissection involves the levels of lymph nodes I to V, the SCM muscle, cranial nerve XI, and the internal
jugular vein. The bed of a radical neck dissection is bounded above by the inferior border of the mandible, below by the clavicle, posteriorly by the anterior
border of the trapezius muscle, and anteriorly by the midline.
In addition to lymphatic tissue, which must be removed as completely as possible, nonlymphatic tissue falls into three categories:
(1) structures that can be sacrificed with impunity;
(2) structures whose sacrifice is controversial, especially for cosmetic reasons; and
(3) structures that must be preserved unless directly invaded by cancer. Structures in these categories are listed in Table 1-17.
Table 1-17. Synopsis of Radical Neck Procedures
Structures May be Sacrificed
Controversial Must be Preserveda
Organs
Submaxillary gland, lower pole of
parotid gland
None
Thyroid gland, parathyroid glands
Muscles
Omohyoid, sternocleidomastoid
Platysma,
digastric,
stylohyoid
All other muscles
Vessels
External jugular vein, facial artery Internal
and vein, superior thyroid artery, jugular vein
lingual artery
External carotid artery, internal carotid artery, subclavian artery and vein, thoracic duct
Nerves
Anterior cutaneous C2-C3,
supraclavicular C3-C4, ansa
hypoglossi, great auricular nerve
Mandibular branch of facial nerve, superior laryngeal nerve, recurrent laryngeal nerve, facial nerve,
lingual nerve, hypoglossal nerve, phrenic nerve, vagus nerve, cervical sympathetic nerve, carotid sinus
nerves, brachial plexus, nerves to rhomboid and serratus muscles
a Unless
Spinal
accessory
nerve
invaded by cancer.
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Source: Skandalakis JE, Gray SW, Rose JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.
Radical neck dissection must be planned as a curative procedure. Because of the morbidity of sacrifice of cranial nerve XI, when nodes in the area are not
enlarged a modified neck dissection is attempted.
The Brazilian Head and Neck Cancer Study Group320 presented results of a trial comparing management of oral squamous carcinoma using modified radical
classical neck dissection and using supraomohyoid neck dissection. The report indicated that the recurrence and survival rates were similar with both
procedures. Supraomohyoid neck dissection was recommended as standard elective treatment for T2-T4 oral squamous cell carcinomas.
SURGICAL ANATOMY
Fascia
Superficial Cervical Fascia
The transverse cervical nerve, greater auricular nerve, lesser occipital nerve, and supraclavicular nerves must be sacrificed. The result is anesthesia of the
posterior scalp, neck, and shoulder.321
There is disagreement about the need for sacrificing the platysma muscle. Some would sacrifice the muscle routinely. Others believe that preservation of the
muscle minimizes scarring and "that once superficial lymphatics are involved, the carcinoma is so widely disseminated that nothing is gained by further
surgical procedures."23
Deep Cervical Fascia
The deep cervical fascia must be removed as completely as possible, because lymph nodes and lymphatic vessels are distributed primarily in the connective
tissue between the layers of the fascia. The carotid sheath and the internal jugular vein also should be sacrificed.
The sternocleidomastoid muscle is used in reconstruction of radical procedures of the neck, therefore knowledge of the blood supply of the muscle perhaps
will minimize the risk of muscle necrosis. Kierner et al.322 reported that "the arterial blood supply of the lower third of the sternocleidomastoid muscle is
constantly provided by a branch of the suprascapular artery."
Triangles
Anterior Triangle
Submental triangle: Remove the entire contents.
Submandibular triangle: Remove the submandibular gland and lymph nodes.
Carotid triangle: Remove the internal jugular vein. High ligation of the vein is facilitated by removal of the lower pole of the parotid gland. The great auricular nerve
and all superficial branches of the cervical nerves should be cut. All lymph nodes along the internal jugular vein must be removed. The final result is shown in Figure 1106.
Fig. 1-106.
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The completed radical dissection of the neck. Remaining structures may be removed if they are involved in malignant growth. (Modified from Skandalakis JE, Gray SW,
Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Posterior Triangle
Remove all tissue above the spinal accessory nerve without injuring the nerve. With blunt dissection, free the nerve from the underlying tissue. Ligate the
external jugular vein close to the subclavian vein, and transect the sternocleidomastoid and omohyoid muscles.
The area beneath the spinal accessory nerve is the "danger zone"23 of Beahrs. It contains several structures that must be identified and saved if possible:
the nerves to the rhomboid and serratus anterior muscles, the brachial plexus, the subclavian artery and vein, and the phrenic nerve with the anterior
scalene muscle between. The object of dissection in this area is to remove completely the transverse cervical (inferior horizontal) and spinal accessory
chains of lymph nodes.
The thoracic duct on the left and the lymphatic duct on the right lie in a mass of areolar connective tissue, deep to the sternocleidomastoid muscle and
posterolateral to the internal jugular vein. Some lymphatic trunks may open independently into the subclavian or jugular veins. They should be preserved if
possible, but if they have been injured, ligate them.
Between the internal jugular vein and the common carotid artery lies the ansa cervicalis, which innervates the strap muscles of the neck. This nerve is on or
in the carotid sheath medial to the internal jugular vein. It may be cut with impunity.
Nerves
Marginal Mandibular Nerve
The marginal mandibular nerve is located in a horizontal (transverse) orientation. It is found just above and superficial to the facial artery and vein, just under
the platysma muscle and above the deep cervical fascia.
Note
The cervical branch of the facial nerve can be cut with impunity since it innervates only the platysma muscle.
The marginal branch innervates the muscles of the lower lip (quadratus labii inferioris and mentalis). Therefore it should be protected not only for functional reasons
but also for cosmetic reasons, to avoid an abnormal facial expression and a highly asymmetrical mouth corner.
An incision in the skin 4-5 cm below the mandibular angle will protect the nerves.
Lingual Nerve
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Lingual Nerve
The lingual nerve, hypoglossal nerve, and the duct of the submandibular gland travel together above (deep to) the mylohyoid muscle. This trio can be seen
after retracting the posterior border of the mylohyoid muscle. The lingual nerve is first seen at a higher level than the submandibular duct; anteriorly,
however, it passes deep to the duct to reach the tongue. The hypoglossal nerve, the most inferior member of the trio, passes horizontally forward in the
upper part of the neck and enters the floor of the mouth by passing deep to the mylohyoid muscle. Thereafter, the hypoglossal nerve passes into the
substance of the tongue, distributing branches to its musculature.
The lingual nerve provides general sensory and taste fibers to the tongue; the hypoglossal nerve provides motor supply to all of the musculature of the
tongue except the palatoglossus, which is supplied by the vagus.
Hypoglossal Nerve
The hypoglossal nerve lies external to the hyoglossus muscle, under and deep to the submandibular gland on its way to the tongue, beneath the posterior
belly of the digastric muscle. This nerve has several fellow travelers, such as the hypoglossal vena comitantes and the lingual artery. The lingual artery
passes deep to the hyoglossus muscle to enter the substance of the tongue. Coursing beside the hypoglossal nerve, the lingual artery may be located above
or below the nerve. Beahrs23 stated that the hypoglossal nerve may be injured in this location. The result is that when protruding, the tongue deviates to
the paralyzed side. This is due to paralysis of all the intrinsic and extrinsic muscles of the tongue, excluding the palatoglossus.
Primary repair of the hypoglossal nerve by microsurgical technique is possible if the injury is recognized during surgery. When the hypoglossal nerve is used to
replace the injured facial nerve, the patient is advised to move the tongue to the injured side when trying to smile. Carney and Anderson323 reported
hypoglossal nerve and internal carotid artery entrapment resulting from an inflammatory process of the surrounding lymph nodes in the area where the nerve
is very close to the artery.
Vagus Nerve
Very rarely the vagus nerve is damaged during radical neck dissection. Even though the nerve is posterior to the common carotid artery and internal jugular
vein and not readily seen, the carotid triad, of which the vagus is a part, is easily recognized. However, if the vagus nerve is involved with tumor, its
sacrifice is necessary.
Phrenic Nerve
The phrenic nerve is located on the ventral surface of the anterior scalene muscle, deep to the prevertebral fascia. Crossing superficial to the nerve are the
lateral branches of the thyrocervical trunk; that is, the transverse cervical and suprascapular arteries. Unilateral paralysis of the hemidiaphragm after division
of the phrenic nerve is tolerated well.
Spinal Accessory Nerve
The pathway of this nerve in the posterior triangle is enigmatic and peculiar. Gordon et al.324 noted that the accessory nerve is vulnerable to injury despite
careful preservation during surgical dissection; it is quite vulnerable in the posterior triangle. Other workers325-327 also emphasized the vulnerability of the
nerve to injury, and cited the occurrence of muscle paralysis "without discernible cause." O'Brien328 reviewed the indications for modified cervical dissections
and methods of sparing the spinal accessory (and other) important regional nerves.
The spinal accessory nerve is said to be located between two layers of fascia and separated from the levator scapulae by a heavy dense fascia. We have
seen this occasionally. We noticed the nerve very close to the skin (0.5-1.5 cm) in the subcutaneous tissue of the posterior triangle. This is the reason that
the nerve is so vulnerable in this area. Its position can be approximated by a line drawn from a point two-thirds of the distance up the posterior border of the
sternocleidomastoid and by another point one-third of the distance up the anterior border of the trapezius.27 The nerve should be protected.329,330
The double layer (superficial and deep) of fascia in this area is also peculiar. The deep layer (prevertebral fascia) is dense, but the superficial layer (investing
layer) is very thin and occasionally unnoticeable. Therefore, we advise that the knife not be used after making the skin incision. Instead, using a hemostat,
carefully separate the tissues in the pathway of the nerve from the posterior border of the sternocleidomastoid muscle, moving obliquely toward the anterior
border of the trapezius muscle where the spinal accessory nerve disappears under the trapezius.
We have seen the spinal accessory nerve bifurcate and trifurcate prior to its disappearance under the trapezius, or bifurcate and trifurcate very close to the
posterior border of the sternocleidomastoid muscle. We have also seen the nerve end at the posterior border of the sternocleidomastoid muscle. The spinal
accessory receives contributions from the 2nd, 3rd, and 4th cervical nerves. Presumably these contributions are sensory in function. However, because of
contributions from C3-C5, some patients have trapezius function even when cranial nerve XI is sacrificed. The lower contributions can occur in the posterior
triangle.
Soo et al.331 stated that the exact motor innervation of the trapezius muscle is controversial. The spinal accessory nerve innervates practically all segments
(regions) of the muscle. However, when the spinal accessory ends in the SCM muscle, the innervation of the trapezius is via C3. In our experience, the
branch from the spinal accessory to the trapezius may diverge from the SCM, joining the branch from C3, thereafter descending to the trapezius.
Brown et al.332 recommended changing the name of the spinal accessory nerve to the spinal accessory nerve plexus, presumably due to the complexity of its
contributions and branching patterns. They noted that with loss of the nerve, paralysis of the trapezius resulted, with drooping and internal rotation of the
shoulder. Zibordi et al.333 presented a very good description of the results of injury to the accessory nerve.
Three to four lymph nodes are very closely associated with the spinal nerve in the posterior triangle. With severe lymphadenitis, the nerve may be fixed with
one lymph node, and accidentally severed during lymph node excisional biopsy in the posterior triangle. According to King and Motta,334 lymph node biopsy
was the predominant reason for injury to the accessory nerve in 37 cases. Brown et al.332 also observed that the accessory nerve was easily removed along
with a lymph node to which it was densely adherent. Donner and Kline335 noted that the spinal accessory nerve was the nerve most commonly injured by
accident.
Decker and DuPlessis336 reported that the occipital artery crossing the hypoglossal nerve gives off a sternomastoid branch which follows the spinal accessory
nerve. The occipital artery very consistently crosses superior to the hypoglossal nerve from anteromedial to posterolateral. As it does so, it gives off the
sternocleidomastoid artery. This artery reaches the muscle parallel with, but inferior to, the point of entrance of the spinal accessory nerve into the SCM.
Thus, this vessel can be helpful in locating the nerve.
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Thus, this vessel can be helpful in locating the nerve.
ANATOMIC COMPLICATIONS
Those who undertake [radical neck dissection] should be aware of the vital importance of an accurate anatomic knowledge of the field before
accepting the responsibility of the treatment of a patient with metastatic disease involving the neck area.—Southwick and Slaughter337
Vascular Injury
Kerth and associates321 stated that the vessels injured in a radical neck dissection are (in order of frequency): the internal and external jugular veins,
subclavian vein, thoracic duct, and carotid artery.
Internal and External Jugular Veins
The internal jugular vein should be ligated as close to the subclavian vein as possible. Venous return will then be through the vertebral, pharyngeal,
pterygoid, esophageal, deep cervical, and occipital venous plexuses. The most important of these is the vertebral plexus.338
Unilateral ligation of external and internal jugular veins produces transient cyanosis and edema of the head. Bilateral ligation or excision must be undertaken
with caution. Martin314 considered simultaneous bilateral ligation "standard procedure in selected cases." However, from the work of several authors,
Zarem339 calculated that there is a 20 percent mortality rate if ligation of both sides is done simultaneously. Zarem would allow at least one month between
ligations to permit the vertebral veins to compensate for increased venous flow.
Too much traction on the internal jugular vein can result in a tear at its lower end. The vein will then retract under the clavicle, requiring the midportion of
the bone to be removed in order to reach and ligate the vein.
Subclavian Vein
Several authors321,337,339 have warned of the danger of air embolism through the internal or external jugular veins or the subclavian vein. The subclavian
vein is the direct continuation of the axillary vein. It is related to the first rib and receives the external jugular vein at the area opposite the middle of the
clavicle. Immediate suturing of the veins is mandatory. The actual mortality rate from air embolism is not known. Pneumothorax and pneumomediastinum also
have been reported.
Thoracic Duct
Postoperative cervical chyle fistula may complicate neck dissection. Nussenbaum et al.340 recommend early operative intervention if the peak 24-hour
drainage is greater than 1000 mL without a prompt response to medical management. They advise that persistent low-output drainage after 10 days is
associated with a prolonged management course and treatment-related complications. Gregor341 advocates total parenteral nutrition to control fluid and
protein loss while avoiding flow of chyle. If the fistula does not resolve, fibrin glue with mesh and muscle flaps is usually successful in achieving closure.
Information about complications of injury to the thoracic duct will be found in the chapter on the lymphatics.
Carotid Artery
Many individuals will tolerate unilateral obstruction of the carotid artery, but this tolerance cannot always be determined prior to operation. Complete
unilateral obstruction of the internal carotid artery carries a great chance of mortality. Moore et al.342 stated that 23% of patients who underwent elective
carotid artery ligation suffered strokes and 17% died. Of the patients undergoing compulsory ligation, 50% suffered strokes and 38% died. Two patients out
of 4 with bilateral carotid artery ligations survived without complications. The axiom by Moore et al. is worth reprinting here:
. . .every effort should be made to preserve the integrity of this vessel [carotid artery], and, if its rupture is deemed inevitable, elective ligation is
preferable to ligation after exsanguinating hemorrhage.
Schmeidek et al.343 reported that all patients with unilateral internal carotid artery occlusion had recurring episodes of focal cerebral ischemia. The
postoperative course of superficial temporal artery-middle cerebral artery anastomosis was uneventful in 23 patients (82%).
Puttini et al.344 reported operative morbidity and mortality of 4.1% in cases of clinical carotid stenosis with contralateral stenosis.
Southwick and Slaughter337 mentioned a case in which the common carotid artery and the vagus nerve were accidentally included in a ligation of the internal
jugular vein.
Pressure from manipulation of the carotid sinus at the bifurcation of the carotid artery can result in serious hypotension. If such pressure cannot be avoided,
infiltration of the area with Xylocaine is suggested.339
Nerve Injury
Spinal Accessory Nerve
Section of the spinal accessory nerve (XI) denervates the trapezius muscle, limiting abduction of the arm and elevation of the shoulder. Subsequent wasting
of the muscle results in a "dropped shoulder." There may be "winging of the superior angle of the scapula." If removal of the nerve is considered unnecessary,
it must be protected from injury. Gordon and colleagues324 reported 17 cases of operations on the posterior triangle in which nerve injury occurred in spite of
care taken to prevent it.
If injury is recognized in the operating room, end-to-end microsurgical anastomosis is the procedure of choice; greater auricular nerve graft is often used. If
the injury is recognized postoperatively, then repair should be done as soon as possible. Repair after the 3rd or 4th month following injury will not be
successful. The sural nerve can be used as a graft if an end-to-end anastomosis is not possible. In comments to Donner and Kline, Hans-Peter Richter345
agreed with Gabel and Nunley346 that the results of nerve repair are far worse if repair is delayed more than 4 months after the initial injury. Tindall,347 in the
same comments, further observed that the nerve was very superficial, merely 1-1.5 cm from the surface of the skin, and thereby injured readily. She stated
that if it could be repaired early, an excellent prognosis could be anticipated.
External Laryngeal and Recurrent Laryngeal Nerves
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External Laryngeal and Recurrent Laryngeal Nerves
Occasionally, these nerves may be injured in radical neck dissection. Injury of the external laryngeal nerve produces inability to tense the cord. Injury of the
recurrent laryngeal results in a paramedian position of the cord, with airway problems.
Ramus Mandibularis of the Facial Nerve
The ramus mandibularis of the facial nerve need not be injured if it is identified and protected. To preserve the nerve, place the incision 4-5 cm below the
angle of the mandible (this also protects the cervical branch). Remembering that the nerve is always above the facial vessels will assist in identification.
Other branches of the facial nerve, and the facial nerve trunk itself should be avoided unless their section is necessary for a tumor of the parotid gland.
We quote from Saffold et al.348:
[S]elective neck dissection performed in a manner preserving the cervical root branches has a small, predictable impact on sensation of the face and
neck. The upper anterior neck between each facial notch of the mandible is the region typically rendered anesthetic. Sacrifice of the cervical root
branches results in a significant extensive sensory deficit involving the entire ipsilateral neck.
Brown et al.349 suggested that the unpredictable postoperative pain and dysfunction that may follow radical neck surgery is likely secondary to the violation
of the blood supply of cranial nerves IX, X, XI and XII, and stressed the importance of sparing as many nerves and vessels as possible.
Brachial Plexus
The upper cord of the brachial plexus is most frequently injured when the connective tissue of the retroclavicular space is removed.337
Remember to preserve the following entities:
Marginal mandibular branch of the facial nerve
Lingual nerve
Hypoglossal nerve
Vagus nerve
Phrenic nerve
Spinal accessory nerve
However, if there is fixation with tumor, the above structures should be sacrificed.
Organ Injury
The thoracic duct can be safely ligated if it is injured. Some surgeons339 suggest routine ligation. The number of lymphatic trunks and their inconstant
anatomy makes it difficult to avoid lymphatic leakage.
Neck Deformity
Ducic and Hilger350 advise unilateral deep plane neck dissection to achieve better symmetry and lessen neck deformity following radical neck dissection.
REFERENCES
1. Eves A. Report of a case of suicidal wound of the throat with profuse haemorrhage successfully treated by ligature of the common carotid artery. Lancet
1849;1:556.
2. Larsen WJ. Human Embryology, 2nd Ed. New York: Churchill Livingstone, 1997, p. 356.
3. Gidvani VK, Bhowmick SK. Midline posterior cervical cystic hygroma. South Med J 1999;92:340-43. [PubMed: 10094282]
4. Miller MB, Cohn AS. Case report: fourth branchial pouch sinus. Ear Nose Throat J 1993;72:356. [PubMed: 8334967]
5. Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma 1979;19:391. [PubMed: 448778]
6. Roden DM, Pomerantz RA. Penetrating injuries to the neck: a safe, selective approach to management. Am Surg 1993;59:750. [PubMed: 8239198]
7. Atteberry LR, Dennis JW, Menawat SS, Frykberg ER. Physical examination alone is safe and accurate for evaluation of vascular injuries in penetrating Zone
II neck trauma. J Am Coll Surg 1994; 179:657. [PubMed: 7952477]
8. Biffl WL, Moore EE, Rehse DH, Offner PJ, Franciose RJ, Burch JM. Selective management of penetrating neck trauma based on cervical level of injury. Am J
Surg 174:678-682, 1997. [PubMed: 9409596]
9. Bumpous JM, Whitt PD, Ganzel TM, McClane SD. Penetrating injuries of the visceral compartment of the neck. Am J Otolaryngol 2000;21:190-194.
[PubMed: 10834554]
10. Demetriades D, Theodorou D, Cornwell E, Berne TV, Asensio J, Belzberg H, Velmahos G, Weaver F, Yellin A. Evaluation of penetrating injuries of the neck:
prospective study of 223 patients. World J Surg 1997;21:41-48. [PubMed: 8943176]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
113/125
5/24/2014
Print: Chapter 1. Neck
11. Britt LD, Cole FJ. "Alternative" surgery in trauma management. Arch Surg 1998;133:1177-1181. [PubMed: 9820347]
12. Sarikcioglu L, Demir S, Oguz N, Sindel M. Anomalous digastric muscle with three accessory bellies and one fibrous band. Surg Radiol Anat 1998;20:453454. [PubMed: 9932332]
13. Kopuz C, Ilgi S, Yavus S, Onderoglu S. Morphology of the retromandibular vein in relation to the facial nerve in the parotid gland. Acta Anat 1995;152:66.
[PubMed: 7604680]
14. Savary V, Robert R, Rogez JM, Armstrong O, Leborgne J. The mandibular marginal ramus of the facial nerve: an anatomic and clinical study. Surg Radiol
Anat 19:69-72, 1997. [PubMed: 9210238]
15. Basar R, Sargon MF, Tekdemir Y, Elhan A. The marginal mandibular branch of the facial nerve. Surg Radiol Anat 19:311-314, 1997. [PubMed: 9413079]
16. Skandalakis JE, Gray SW, Rowe JS Jr. Surgical anatomy of the submandibular triangle. Am Surg 1979;45:590. [PubMed: 507567]
17. Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg
1962;29:266. [PubMed: 13886490]
18. Wang TM, Lin CL, Kuo KJ, Shih C. Surgical anatomy of the mandibular ramus of the facial nerve in Chinese adults. Acta Anat 1991;142:126. [PubMed:
1781251]
19. Jovanovic MS. The mandibulo-stylohyoid ligament (tractus angularis). Surg Radiol Anat 1990;12:91. [PubMed: 2396186]
20. DuPlessis DJ. A Synopsis of Surgical Anatomy (11th ed). Bristol: Wright and Sons, 1975.
21. Sehirli Ü, Çavdar S. An accessory mylohyoid muscle. Surg Radiol Anat 1996;18:57-59. [PubMed: 8685814]
22. Lindner HH. The anatomy of the fasciae of the face and neck with particular reference to the spread and treatment of intraoral infections (Ludwig's) that
have progressed into adjacent fascial spaces. Ann Surg 1986;204:705. [PubMed: 3789840]
23. Beahrs OH. The surgical anatomy and technique of parotidectomy. Surg Clin North Am 1977;57:477. [PubMed: 325670]
24. Singhabhandhu B, Gray SW, Bryant MF, Skandalakis JE. Carotid body tumors. Am Surg 1973;39:501. [PubMed: 4725805]
25. Grant JCB, Basmajian JV. Grant's Method of Anatomy, 7th Ed. Baltimore: Williams & Wilkins, 1965, p. 553.
26. Kierner AC, Zelenka I, Heller S, Burian M. Surgical anatomy of the spinal accessory nerve and the trapezius branches of the cervical plexus. Arch Surg
2000;135:1428-1431. [PubMed: 11115348]
27. Kline DG, Hudson AR, Kim DH. Atlas of Peripheral Nerve Surgery. Philadelphia: WB Saunders, 2001.
28. Winnie AP. Plexus anesthesia. In: Winnie AP, Hakansson L, Buckhoj P (eds). Perivascular Techniques of Brachial Plexus Block (vol 1). Philadelphia: WB
Saunders, 1993.
29. Harry WG, Bennett JDC, Guha SC. Scalene muscles and the brachial plexus: anatomical variations and their clinical significance. Clin Anat 10:250-252,
1997. [PubMed: 9213042]
30. Kunkel JM, Machleder HI. Treatment of Paget-Schroetter disease. Arch Surg 1989;124:1153. [PubMed: 2529837]
31. Obuchowski AM, Ortiz AO. MR imaging of the thoracic inlet. Magn Reson Imaging Clin North Am 2000;8:183-203, ix-x.
32. Sanders RJ, Pearce WH. The treatment of thoracic outlet syndrome: a comparison of different operations. J Vasc Surg 1989;10:626. [PubMed: 2585651]
33. Makhoul RG, Machleder HI. Developmental anomalies at the thoracic outlet: an analysis of 200 consecutive cases. J Vasc Surg 1992;16:534-545.
[PubMed: 1404675]
34. Machleder HI, Moll F, Verity MA. The anterior scalene muscle in thoracic outlet compression syndrome. Arch Surg 1986;121:1141. [PubMed: 3767646]
35. Flye MW. Disorders of veins. In Sabiston DC Jr. Textbook of Surgery, 13th Ed. Philadelphia: WB Saunders, 1986, pp. 1709-1730.
36. Hollinshead WH. Anatomy for Surgeons (2nd ed). New York: Harper & Row, 1968.
37. Grodinsky M, Holyoke EA. The fasciae and fascial spaces of the head, neck and adjacent regions. Am J Anat 1938;63:367.
38. Coller FA, Yglesias L. The relation of the spread of infection to fascial planes in the neck and thorax. Surgery 1937;1:323.
39. Buser KB, Bart G. Surgical implications of the retropharyngeal space. Am Surg 1984;50:33. [PubMed: 6691632]
40. Pearse HE Jr. Mediastinitis following cervical suppuration. Ann Surg 1938;108:588.
41. Montgomery RL. Head and Neck Anatomy: With Clinical Correlations. New York: McGraw-Hill, 1981.
42. Johnson CA, Tollefson DFJ, Olsen SB, Andersen CA, McKee-Johnson J. The natural history of early recurrent carotid artery stenosis. Am J Surg
1999;177:433-436. [PubMed: 10365886]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
114/125
5/24/2014
Print: Chapter 1. Neck
1999;177:433-436. [PubMed: 10365886]
43. Lucev N, Bobinac D, Maric I, Drescik I. Variations of the great arteries in the carotid triangle. Otolaryngol Head Neck Surg 2000;122:590-591. [PubMed:
10740186]
44. Cole RD, May JS. Aberrant internal carotid artery. South Med J 1994; 87:1277. [PubMed: 7973930]
45. Papon X, Pasco A, Fournier HD, Mercier P, Cronier P, Pillet J. Anastomosis between the internal carotid and vertebral artery in the neck. Surg Radiol Anat
1995;17:335-337. [PubMed: 8896154]
46. Meder JF, Blustajn J, Trystram D, Godon-Hardy S, Devaux B, Zuber M, Frédy D. Radiologic anatomy of segmental agenesis of the internal carotid artery.
Surg Radiol Anat 19:385-394, 1997. [PubMed: 9479713]
47. Carsten CG III, Elmore JR, Franklin DP, Thomas DD, Mordan F, Wood GC. Use of limited color-flow Doppler duplex for a carotid screening project. Am J Surg
1999;178:174-177.
48. Wind GG, Valentine RJ. Anatomic Exposures in Vascular Surgery. Baltimore: Williams & Wilkins, 1991.
49. Roberts B, Hardesty WH, Holling HE, Reivich M, Toole JF. Studies on extracranial cerebral blood flow. Surgery 1964:56:826.
50. Dandy WE. Intracranial Arterial Aneurysms. Ithaca NY: Comstock, 1944.
51. Dandy WE. Results following bands and ligatures on the human internal carotid artery. Ann Surg 1946;123:384.
52. Pemberton JdeJ, Livermore GR Jr. Surgical treatment of carotid body tumors: value of anticoagulants in carotid ligation. Ann Surg 1951;133:837-852.
[PubMed: 14838528]
53. Drake CG, Peerless SJ, Ferguson GC. Hunterian proximal arterial occlusion for giant aneurysms of the carotid circulation. J Neurosurg 1994;81:656.
[PubMed: 7931611]
54. Kuehne JP, Weaver FA, Papanicolaou G, Yellin AE. Penetrating trauma of the internal carotid artery. Arch Surg 131:942-948, 1996. [PubMed: 8790179]
55. Blaisdell FW. Discussion. Kuehne JP, Weaver FA, Papanicolaou G, Yellin AE. Penetrating trauma of the internal carotid artery. Arch Surg 131:942-948,
1996.
56. Okamoto Y, Inugami A, Matsuzaki Z, Yokomizo M, Konno A, Togawa K, Kuribayashi R, Ogawa T, Kanno I. Carotid artery resection for head and neck
cancer. Surgery 120(1):54-59, 1996.
57. Marien BJ, Thompson RM. Anomalous branch of the cervical internal carotid artery. Contemp Surg 1998;53(5):332-334.
58. Ballotta E, Da Giau G, Renon L, Narne S, Saladini M, Abbruzzese E, Meneghetti G. Cranial and cervical nerve injuries after carotid endarterectomy: A
prospective study. Surgery 1999;125:85-91. [PubMed: 9889802]
59. Guterman LR, Fessler RD, Hopkins LN. Cervical carotid revascularization. Neurosurg Clin North Am 2000;11:39-48. [PubMed: 10565869]
60. Russell RCG, Williams NS, Bulstrode CJK (eds). Bailey & Love's Short Practice of Surgery (23rd ed). London: Arnold, 2000, p. 704.
61. Williams PL (ed). Gray's Anatomy (38th ed). New York: Churchill Livingstone, 1995.
62. Drinker CK, Yoffey JM. Lymphatics, Lymph, and Lymphoid Tissue. Cambridge MA: Harvard University Press, 1941, p 12.
63. Mancuso AA, Harnsberger HR, Muraki AS, Stevens MH. Computed tomography of cervical and retropharyngeal lymph nodes: normal anatomy, variants of
normal, and applications in staging head and neck cancer. Part I: normal anatomy. Radiology 1983:148:709.
64. Mancuso AA, Harnsberger HR, Muraki AS, Stevens MH. Computed tomography of cervical and retropharyngeal lymph nodes: normal anatomy, variants of
normal, and applications in staging head and neck cancer. Part II: pathology. Radiology 1983;148:715. [PubMed: 6878692]
65. Healey JE Jr. A Synopsis of Clinical Anatomy. Philadelphia: Saunders, 1969.
66. Kraus DH, Rosenberg DB, Davidson BJ, Shaha AR, Spiro RH, Strong EW, Schantz SP, Shah JP. Supraspinal accessory lymph node metastases in
supraomohyoid neck dissection. Am J Surg 172:646-649, 1996. [PubMed: 8988668]
67. Skandalakis JE, Androulakis JA. Swelling of the neck: a statistical analysis of 7,748 cases with emphasis on differential diagnosis of nonthyroid tumors. In:
Volume in Honor of BG Kourias. Athens, Greece: O Logos, 1975.
68. Lyles A, Johns ME, Johns MME. Fine needle aspiration of head and neck mass. In: Eiseman BE (ed). Cost-Effective Otolaryngology. New York: Decker,
1990, p. 179-186.
69. Feldman PS, Kaplan MJ, Johns ME, Cantrell RW. Fine-needle aspiration in squamous cell carcinoma of the head and neck. Arch Otolaryngol 1983;109:735742. [PubMed: 6639441]
70. Lee DJ, Rostock RA, Harris A, Kashima H, Johns M. Clinical evaluation of patients with metastatic squamous carcinoma of the neck with occult primary
tumor. South Med J 1986;79:979-983. [PubMed: 3738594]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
115/125
5/24/2014
Print: Chapter 1. Neck
71. Johns ME. The clonal assay of head and neck tumor cells: results and clinical correlations. Laryngoscope 1982;92(Suppl 28, No. 7, Pt. 2):1-26.
72. Johns ME, Mills SE. Cloning efficiency: a possible prognostic indicator in squamous cell carcinoma of the head and neck. Cancer 1983;52:1401-1404.
[PubMed: 6616405]
73. Johns ME, Mills SE, Thompson KK. Colony-forming assay of human salivary gland tumors. Arch Otolaryngol 1983;109:709-714. [PubMed: 6314953]
74. Davis HK. A statistical study of the thoracic duct in man. Am J Anat 1915:17:211.
75. Wechselberger G, Schoeller T, Otto A. Treatment of chronic thoracic duct fistula with the sternocleidomastoid muscle flap. Am J Surg 1998;176:471-474.
[PubMed: 9874436]
76. McGregor AL, DuPlessis DJ. A Synopsis of Surgical Anatomy, 10th Ed. Baltimore: Williams and Wilkins, 1969.
77. McVay CB. Anson & McVay Surgical Anatomy, 6th Ed. Philadelphia: WB Saunders, 1984.
78. Kuntz A. Distribution of the sympathetic rami to the brachial plexus. Arch Surg 1927;15:871-877.
79. Kuntz A. The Autonomic Nervous System (4th ed). Philadelphia: Lea & Febiger, 1953.
80. Platzer W. Atlas of Topographical Anatomy. Stuttgart: Georg Thieme Verlag, 1985.
81. Pearse AGE, Polak JM. Cytochemical evidence for the neural crest origin of mammalian ultimobranchial C cells. Histochemie 1971;27:96. [PubMed:
5092696]
82. Welbourn RB. Current status of the apudomas. Ann Surg 1977;185:1. [PubMed: 12724]
83. Skandalakis JE, Gray SW. Embryology for Surgeons (2nd ed). Baltimore: Williams & Wilkins, 1994.
84. LiVolsi VA. Developmental biology and anatomy of the thyroid, including the aberrant thyroid. In: Bennington JL (ed). Surgical Pathology of the Thyroid.
Vol 22 in the series Major Problems in Pathology. Philadelphia: WB Saunders, 1990, p. 7.
85. Gray SW, Skandalakis JE. Embryology for Surgeons (1st ed). Philadelphia: Saunders, 1972.
86. Kamat MR, Kulkarni JN, Desai PB, Jusswalla DJ. Lingual thyroid: a review of 12 cases. Br J Surg 1979;66:537. [PubMed: 486909]
87. Gray SW, Skandalakis JE, Androulakis JA. Nonthyroid tumors of the neck. Contemp Surg 26:13-24, 1985.
88. LiVolsi VA, Perzin KH, Savetsky L. Ectopic thyroid (including thyroglossal duct tissue). Cancer 34:1303-1315, 1974. [PubMed: 4421377]
89. Allard RHB. The thyroglossal cyst. Head Neck Surg 5:134-146, 1982. [PubMed: 7169333]
90. Nussbaum M, Buchwald RP, Ribner A, Mori K, Litwins JO. Anaplastic carcinoma arising from median ectopic thyroid (thyroglossal duct remnant). Cancer
48:2724-2728, 1981. [PubMed: 7306927]
91. Walton BR, Koch KE. Presentation and management of a thyroglossal duct cyst with a papillary carcinoma. South Med J 90(7):758-761, 1997.
92. Wang CY, Chang TC. Preoperative thyroid ultrasonography and fine-needle aspiration cytology in ectopic thyroid. Am Surg 61(12):1029-1031, 1995.
93. Stahl WM Jr, Lyall D. Cervical cysts and fistulae of thyroglossal tract origin. Ann Surg 1954;139:123. [PubMed: 13114863]
94. Quigley WF, Williams LF, Hughes CW. Surgical management of subhyoid median ectopic thyroid. Ann Surg 1962;155:305. [PubMed: 14489488]
95. Bhatnagar KP, Nettleton GS, Wagner CE. Subisthmic accessory thyroid gland in man: a case report and a review of thyroid anomalies. Clin Anat 10:341344, 1997. [PubMed: 9283734]
96. Monchik JM, Materazzi G. The necessity for a thoracic approach in thyroid surgery. Arch Surg 2000;135:467-471. [PubMed: 10768714]
97. Kumar R, Khullar S, Gupta R, Marwah A, Drm MA. Dual thyroid ectopy: case report and review of the literature. Clin Nucl Med 2000;25:253-254. [PubMed:
10750961]
98. LiVolsi VA. Surgical Pathology of the Thyroid. Philadelphia: WB Saunders, 1990.
99. Sawicki MP, Howard TJ, Passaro E Jr. Heterotopic tissue in lymph nodes: an unrecognized problem. Arch Surg 1990;125:1394. [PubMed: 2222180]
100. Rubenfeld S, Joseph UA, Schwartz MR, Weber SC. Ectopic thyroid in the right carotid triangle. Arch Otolaryngol Head Neck Surg 1988;114:913-915.
[PubMed: 3390337]
101. Woodruff JD, Rauh JT, Markley RL. Ovarian struma. Obstet Gynecol 1966;27:194. [PubMed: 5909538]
102. Kempers RD, Dockerty MB, Hoffman DL, Bartholomew LG. Struma ovarii: ascitic, hyperthyroid and asymptomatic syndromes. Ann Intern Med
1970;72:883-893. [PubMed: 5448747]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
116/125
5/24/2014
Print: Chapter 1. Neck
103. Yannopoulos D, Yannopoulos K, Ossowski R. Malignant struma ovarii. Pathol Ann 1976;11:403. [PubMed: 1004942]
104. Rosenblum NG, LiVolsi VA, Edmonds PR. Malignant struma ovarii. Gynecol Oncol 1989;32:224-227. [PubMed: 2910784]
105. Falor WH, Meyer EG, Bratcher E, Azarfahimi A, Sharp WV. The right thoracic duct in man: technique of exposure and variations in anatomy. Bull Akron
City Hosp 1963;5:1.
106. Polluck WF. Surgical anatomy of the thyroid and parathyroid glands. Surg Clin North Am 1964;44:1161.
107. Foster RS Jr, Hunter JG, Spivak H, Smith CD. Adrenal glands. In: Wood WC, Skandalakis JE. Anatomic Basis of Tumor Surgery. St. Louis: Quality Medical
Publishing, 1999, pp. 783-824.
108. Mastin EV. The blood supply of the thyroid gland and its surgical significance. Surg Gynecol Obstet 1923;36:69.
109. Nobori M, Saiki S, Tanaka N, Harihara Y, Shindo S, Fujimoto Y. Blood supply of the parathyroid gland from the superior thyroid artery. Surgery
1994;115:417-423. [PubMed: 8165531]
110. Weiglein AH. A rare variant of thyroid gland vascularization. Surg Radiol Anat 1996;18:233-235. [PubMed: 8873339]
111. Daseler EH, Anson BJ. Surgical anatomy of the subclavian artery and its branches. Surg Gynecol Obstet 1959;108:149. [PubMed: 13625063]
112. Hunt PS, Poole M, Reeve TS. A reappraisal of the surgical anatomy of the thyroid and parathyroid glands. Br J Surg 1968;55:63. [PubMed: 5635426]
113. Allan FD. An accessory or superficial inferior thyroid artery in a full term infant. Anat Rec 1952;112:539. [PubMed: 14924247]
114. Kriss JP, Konishi J, Herman M. Studies on the pathogenesis of Graves' ophthalmology (with some related observations regarding therapy). Recent Prog
Horm Res 1975;31:533. [PubMed: 1105721]
115. Földi M, Kukán F, Szegy G, Géllert A, Kozma M, Poberai M, Zoltan OT, Varga L. Anatomical, histological and experimental data on fluid circulation of the
eye. Acta Anat 1963;53:333. [PubMed: 16453386]
116. Mahorner HR, Caylor HD, Schlotthauer CF, Pemberton J de J. Observations on the lymphatic connections of the thyroid gland in man. Anat Rec
1927;36:341.
117. Gemsenjäger E, Heitz PU, Martina B. Selective treatment of differentiated thyroid carcinoma. World J Surg 21:546-552, 1997.
118. Feind CR. The head and neck. In: Haagensen CD, Feind CR, Herter FP, Slanetz CA Jr, Weinberg JA (eds). The Lymphatics in Cancer. Philadelphia:
Saunders, 1972.
119. Shaha AR, Shah JP, Loree TR. Patterns of nodal and distant metastasis based on histologic varieties in differentiated carcinoma of the thyroid. Am J
Surg 172:692-694, 1996. [PubMed: 8988680]
120. Katz AD, Nemiroff P. Anastomoses and bifurcations of the recurrent laryngeal nerve: report of 1177 nerves visualized. Am Surg 1993;59:188. [PubMed:
8476158]
121. Nemiroff PM, Katz AD. Extralaryngeal divisions of the recurrent laryngeal nerve. Am J Surg 1982;144:466-469. [PubMed: 7125080]
122. Skandalakis JE, Droulias C, Harlaftis N, Tzinas S, Gray SW, Akin JT Jr. Recurrent laryngeal nerves. Am Surg 1976;42:629. [PubMed: 949131]
123. Berlin DD. The recurrent laryngeal nerves in total ablation of the normal thyroid gland. Surg Gynecol Obstet 1935;60:19.
124. Schweizer V, Dörfl J. The anatomy of the inferior laryngeal nerve. Clin Otolaryngol 1997;22:362-369. [PubMed: 9298614]
125. Reed AF. The relations of the inferior laryngeal nerve to the inferior thyroid artery. Anat Rec 1943;85:17.
126. Lekacos NL, Tzardis PJ, Sfikakis PG, Patoulis SD, Restos SD. Course of the recurrent laryngeal nerve relative to the inferior thyroid artery and the
suspensory ligament of Berry. Int Surg 1992;77:287. [PubMed: 1478811]
127. Kreyer R, Pomaroli A. Anastomosis between the external branch of the superior laryngeal nerve and the recurrent laryngeal nerve. Clin Anat 2000;13:7982. [PubMed: 10679851]
128. Sturniolo G, D'Alia C, Tonante A, Gagliano E, Taranto F, Lo Schiavo MG. The recurrent laryngeal nerve related to thyroid surgery. Am J Surg
1999;177:485-488. [PubMed: 10414699]
129. Procacciante F, Picozzi P, Pacifici M, Picconi S, Ruggeri S, Fantini A, Basso N. Palpatory method used to identify the recurrent laryngeal nerve during
thyroidectomy. World J Surg 2000; 24:571-573.
130. Marchesi M, Biffoni M, Faloci C, Nobili Benedetti R, Notari P, Mariotti F, Cresti R. [The inferior nonrecurrent laryngeal nerve: a report of 7 cases observed
since 1987]. Giornale Chir 2000;21: 25-28. [PubMed: 10732377]
131. Avisse C, Marcus C, Delattre JF, Marcus C, Cailliez-Tomasi JP, Palot JP, Landam-Marcus V, Menanteau B, Flament JB. Right nonrecurrent inferior
laryngeal nerve and arteria lusoria: the diagnostic and therapeutic implications of an anatomic anomaly: Review of 17 cases. Surg Radiol Anat 1998;20:22732. [PubMed: 9706684]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
117/125
5/24/2014
32. [PubMed: 9706684]
Print: Chapter 1. Neck
132. Sanders G, Uyeda RY, Karlan MS. Nonrecurrent inferior laryngeal nerves and their association with a recurrent branch. Am J Surg 1983;146:501-503.
[PubMed: 6625095]
133. Miyauchi A, Matsusaka K, Kawaguchi H, Nakamoto K, Maeda M. Ansa-recurrent nerve anastomosis for vocal cord paralysis due to mediastinal lesions.
Ann Thorac Surg 1994;57:1020. [PubMed: 8166501]
134. Steinberg JL, Khane GJ, Fernandes CM, Nel JP. Anatomy of the recurrent laryngeal nerve: a redescription. J Laryngol Otol 1986;100:919. [PubMed:
3746108]
135. Herranz-Gonzalez J, Gavilan J, Martinez-Vidal J, Gavilan C. Complications following thyroid surgery. Arch Otolaryngol Head Neck Surg 1991;117:516.
[PubMed: 2021469]
136. Prioleu WH. Injury to the laryngeal branches of the vagus nerve in thyroid surgery. South Surg 1933;1:287.
137. Riddell V. Thyroidectomy: prevention of bilateral recurrent nerve palsy. Br J Surg 1970;57:1. [PubMed: 5411583]
138. Jatzko GR, Lisborg PH, Muller MG, Wette VM. Recurrent nerve palsy after thyroid operations: principal nerve identification and a literature review.
Surgery 1994;115:139. [PubMed: 8310401]
139. Wang C. The anatomic basis of parathyroid surgery. Ann Surg 183:271, 1976. [PubMed: 1259483]
140. Pelizzo MR, Toniato A, Gemo G. Zuckerkandl's tuberculum: an arrow pointing to the recurrent laryngeal nerve (constant anatomical landmark). J Am Coll
Surg 1998;187:333-336. [PubMed: 9740193]
141. Falk SA (ed). Thyroid Disease: Endocrinology, Surgery, Nuclear Medicine, and Radiotherapy, 2nd ed. Philadelphia: Lippincott-Raven, 1997.
142. Thompson NW. Thyroid gland. In Greenfield LJ (ed). Surgery: Scientific Principles and Practice. Philadelphia: Lippincott-Raven, 1997, pp. 1283-1308.
143. Dedo HH. The paralyzed larynx: an electromyographic study in dogs and humans. Laryngoscope 1970;80:1455. [PubMed: 4921200]
144. Sun SQ, Dong JP. An applied anatomical study of the superior laryngeal nerve loop. Surg Radiol Anat 1997;19:169-173. [PubMed: 9381318]
145. el-Guindy A, Abdel-Aziz M. Superior laryngeal nerve preservation in peri-apical surgery by mobilization of the viscerovertebral angle. J Laryngol Otol
2000;114;268-273.
146. Horiuchi M, Sasaki CT. Cricothyroid muscle in respiration. Ann Otol Rhinol Laryngol 1978;87:386.
147. Wu BL, Sanders I, Mu L, Biller HF. The human communicating nerve: an extension of the external superior laryngeal nerve that innervates the vocal cord.
Arch Otolaryngol 1994;120:1321. [PubMed: 7980895]
148. Cernea CR, Nishio S, Hojaij FC. Identification of the external branch of the superior laryngeal nerve (EBSLN) in large goiters. Am J Otolaryngol
1995;16:307. [PubMed: 7503373]
149. Cernea CR, Ferraz AR, Furlani. Identification of the external branch of the superior laryngeal nerve during thyroidectomy. Am J Surg 1992;164:634.
[PubMed: 1463114]
150. Cernea CR, Ferraz AR, Nishio S. Surgical anatomy of the external branch of the superior laryngeal nerve. Head Neck 1992; 14:380. [PubMed: 1399571]
151. Mooseman DA, DeWeese MS. The external laryngeal nerve as related to thyroidectomy. Surg Gynecol Obstet 1968;127:1011.
152. Ross MH, Reith EJ. Histology: A Text and Atlas. New York: Harper & Row, 1985, pp. 574-579.
153. Ferzli GS, Sayad P, Abdo Z, Cacchione RN. Minimally invasive, nonendoscopic thyroid surgery. J Am Coll Surg 2001;192:665-668. [PubMed: 11333106]
154. Bliss RD, Gauger PG, Delbridge LW. Surgeon's approach to the thyroid gland: surgical anatomy and the importance of technique. World J Surg
2000;24:891-897. [PubMed: 10865032]
155. Johns ME. The solitary thyroid nodule. Curr Ther Otolaryngol 1987;3:226-229.
156. Delbridge L, Guinea AI, Reeve TS. Total thyroidectomy for bilateral benign multinodular goiter. Arch Surg 1999;134:1389-1393. [PubMed: 10593340]
157. Cooper DS. Radioiodine for hyperthyroidism: where do we stand after 50 years? JAMA 280(4):375-376, 1998.
158. Ron E, Doody MM, Becker DV, Brill AB, Curtis RE, Goldman MB, Harris BSH III, Hoffman DA, McConahey WM, Maxon HR, Preston-Martin S, Warshauer ME,
Wong FL, Boice JD. Cancer mortality following treatment for adult hyperthyroidism. JAMA 280(4):347-355, 1998.
159. Skandalakis JE, Rand EO, Poer DH. Malignant tumors of the thyroid gland. J Med Assoc of Georgia 47(4):165-171, 1958.
160. Noguchi S, Noguchi A, Murakami N. Papillary carcinoma of the thyroid. I. Developing patterns of metastasis. Cancer 1970;26: 1053-1060. [PubMed:
5476786]
161. Mirallié E, Visset J, Sagan C, Hamy A, Le Bodic MF, Paineau J. Localization of cervical node metastasis of papillary thyroid carcinoma. World J Surg
1999;23:970-974.
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
118/125
5/24/2014
Print: Chapter 1. Neck
162. Clark OH. Invited commentary. Mirallié E, Visset J, Sagan C, Hamy A, Le Bodic MF, Paineau J. Localization of cervical node metastasis of papillary thyroid
carcinoma. World J Surg 1999;23:970-974.
163. Chen H, Nicol TL, Udelsman R. Clinically significant, isolated metastatic disease to the thyroid gland. World J Surg 1999;23: 177-181. [PubMed: 9880428]
164. Boyd LA, Earnhardt RC, Dunn JT, Frierson HF, Hanks JB. Preoperative evaluation and predictive value of fine-needle aspiration and frozen section of
thyroid nodules. J Am Coll Surg 1998;187:494-502. [PubMed: 9809565]
165. Tarantino DR, McHenry CR, Strickland T, Khiyami A. The role of fine-needle aspiration biopsy and flow cytometry in the evaluation of persistent neck
adenopathy. Am J Surg 1998;176: 413-417. [PubMed: 9874424]
166. Matsuzuka F, Fukata S, Kuma K, Miyauchi A, Kakudo K, Sugawara M. Gene rearrangement of immunoglobulin as a marker of thyroid lymphoma. World J
Surg 22:558-561, 1998. [PubMed: 9597928]
167. Smith P, Brown B, Gray SW, Skandalakis JE. Primary Hodgkin's disease of the thyroid gland. J Med Assoc Georgia, 75:538-540, 1986. [PubMed: 3772270]
168. Hermann M, Roka R, Richter B, Koriska K, Göbl S, Freissmuth M. Reoperation as treatment of relapse after subtotal thyroidectomy in Graves' disease.
Surgery 1999;125:522-528. [PubMed: 10330941]
169. Lo CY, Lam KY, Wan KY. Anaplastic carcinoma of the thyroid. Am J Surg 1999;177:337-339. [PubMed: 10326855]
170. Dhar DK, Kubota H, Kotoh T, Tabara H, Watanabe R, Tachibana M, Kohno H, Nagasue N. Tumor vascularity predicts recurrence in differentiated thyroid
carcinoma. Am J Surg 1998;176:442-447. [PubMed: 9874430]
171. Sanders LE, Silverman M. Follicular and Hürthle cell carcinoma: predicting outcome and directing therapy. Surgery 1998;124:967-974. [PubMed:
9854570]
172. Gauger PG, Reeve TS, Delbridge LW. Intraoperative decision making in follicular lesions of the thyroid: Is tumor size important? J Am Coll Surg
1999;189:253-258. [PubMed: 10472925]
173. Machens A, Hinze R, Lautenschläger C, Thomusch O, Dralle H. Thyroid carcinoma invading the cervicovisceral axis: routes of invasion and clinical
implications. Surgery 2001;129:23-28.
174. Gimm O, Ukkat J, Dralle H. Determinative factors of biochemical cure after primary and reoperative surgery for sporadic medullary thyroid carcinoma.
World J Surg 22:562-568, 1998. [PubMed: 9597929]
175. Hay ID, Grant CS, Bergstralh EJ, Thompson GB, van Heerden JA, Goellner JR. Unilateral total lobectomy: is it sufficient surgical treatment for patients
with AMES low-risk papillary thyroid carcinoma? Surgery 124:958-964, 1998. [PubMed: 9854569]
176. Dralle H, Gimm O, Simon D, Frank-Raue K, Görtz G, Niederle B, Wahl RA, Koch B, Walgenbach S, Hampel R, Ritter MM, Spelsberg F, Heiss A, Hinze R,
Höppner W. Prophylactic thyroidectomy in 75 children and adolescents with hereditary medullary thyroid carcinoma: German and Austrian experience. World J
Surg 22, 744-751, 1998.
177. Kebebew E, Kikuchi S, Duh QY, Clark OH. Long-term results of reoperation and localizing studies in patients with persistent or recurrent medullary thyroid
cancer. Arch Surg 2000;135:895-901. [PubMed: 10922248]
178. Voutilainen PE, Multanen M, Haapianen RK, Leppäniemi AK, Sivula AH. Anaplastic thyroid carcinoma survival. World J Surg 1999;23:975-979. [PubMed:
10449831]
179. Nilsson O, Lindeberg J, Zedenius J, Ekman E, Tennvall J, Blomgren H, Grimelius L, Lundell G, Wallin G. Anaplastic giant cell carcinoma of the thyroid gland:
treatment and survival over a 25-year period. World J Surg 1998;22:725-730. [PubMed: 9606289]
180. Hamoir E, Meurisse M, Defechereux T, Joris J, Vivario J, Hennen G. Surgical management of amiodarone-associated thyroxicosis: too risky or too
effective? World J Surg 22:537-543, 1998. [PubMed: 9597925]
181. Chao T-C, Lin J-D, Jeng L-B, Chen M-F. Thyroid cancer with concurrent hyperthyroidism. Arch Surg 1999;134:130-134. [PubMed: 10025449]
182. Shimizu K, Akira S, Jasmi AY, Kitamura Y, Kitagawa W, Akasu H, Tanaka S. Video-assisted neck surgery: Endoscopic resection of thyroid tumors with a
very minimal neck wound. J Am Coll Surg 1999;188:697-703. [PubMed: 10359365]
183. Yang CC, Lee CH, Wang LS, Huang BS, Hsu WH, Huang MH. Resectional treatment for thyroid cancer with tracheal invasion: a long-term follow-up
study. Arch Surg 2000;135:704-707. [PubMed: 10843368]
184. Pandya S, Sanders L. Use of a Foley catheter in the removal of a substernal goiter. Am J Surg 175:155-157, 1998. [PubMed: 9515535]
185. Conley JJ. Complications of Head and Neck Surgery. Philadelphia: Saunders, 1979.
186. Scanlon EF, Kellogg JE, Winchester DP, Larson RH. The morbidity of total thyroidectomy. Arch Surg 1981;116:568. [PubMed: 7235947]
187. Fernando DA, Lord RSA. The blood supply of the vagus nerve in the human: its implication in carotid endarterectomy, thyroidectomy and carotid arch
aneurectomy. Ann Anat 1994;176:333-337. [PubMed: 8085656]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
119/125
5/24/2014
aneurectomy. Ann Anat 1994;176:333-337. [PubMed: 8085656]
Print: Chapter 1. Neck
188. Holt GR, McMurry GT, Joseph DJ. Recurrent laryngeal nerve injury following thyroid operations. Surg Gynecol Obstet 1977; 144:567. [PubMed: 847613]
189. Lahey FH, Hoover WB. Injuries to the recurrent laryngeal nerves in thyroid operations. Ann Surg 1938;108:545.
190. Chang-Chien Y. Surgical anatomy and vulnerability of the recurrent laryngeal nerve. Int Surg 1980;65:23.
191. Esmeraldo R, Paloyan E, Laurence AM. Thyroidectomy, parathyroidectomy and modified neck dissection. Surg Clin North Am 1977;57:495.
192. Neel HB, Townsend GL, Devine KD. Bilateral vocal cord paralysis of undetermined etiology. Ann Otol 1972;81:514. [PubMed: 4341132]
193. Katz AD. Extralaryngeal division of the recurrent laryngeal nerve. Am J Surg 1986;152:407. [PubMed: 3766872]
194. Lekacos NL, Miligos ND, Tzardis PJ, Majiatis S, Patoulis J. The superior laryngeal nerve in thyroidectomy. Am Surg 1987;53:610. [PubMed: 3674608]
195. Durham CG, Harrison TS. The surgical anatomy of the superior laryngeal nerve. Surg Gynecol Obstet 1964;118:34.
196. Johns ME, Rood SR. Vocal Chord Paralysis: Diagnosis and Management. Washington DC: American Academy of Otolaryngology, 1987.
197. Harlaftis N, Tzinas S, Droulias C, Akin JT Jr, Gray SW, Skandalakis JE. Rare complications of thyroid surgery. Am Surg 1976;42:645-647. [PubMed:
949134]
198. Farquharson EL, Rintoul RF. Textbook of Operative Surgery (5th ed). Edinburgh: Churchill Livingstone, 1972.
199. Paparella MM, Shumrick DA. Otolaryngology (2nd ed). Philadelphia: WB Saunders, 1980.
200. Wilson TG. Diseases of the Ear, Nose and Throat in Children (2nd ed). London: William Heineman, 1962.
201. Stell PM, Maran AGD. Head and Neck Surgery (2nd ed). London: William Heineman, 1978.
202. Yerzingatsian KL. Surgical anatomy of structures adjacent to the thyroid apex and post-operative voice change (a review including dissection). J
Laryngol Otol Suppl 1987;14:1. [PubMed: 3320235]
203. Yerzingatsian KL. Thyroidectomy under local analgesia: the anatomical basis of cervical blocks. Ann R Coll Surg Engl 1989;71:207. [PubMed: 2774445]
204. Chao TC, Jeng LB, Lin JD, Chen MF. Reoperative thyroid surgery. World J Surg 21:644-647, 1997. [PubMed: 9230664]
205. Profanter C, Klingler A, Strolz S, Wetscher GJ, Promegger R, Bodner E, Riccabona G. Surgical therapy for primary hyperparathyroidism in patients with
previous thyroid surgery. Am J Surg 1999;178:374-376. [PubMed: 10612530]
206. Menegaux F, Turpin G, Dahman M, Leenhardt L, Chadaevian R, Aurengo A, du Pasquier L, Chigot JP. Secondary thyroidectomy in patients with prior
thyroid surgery for benign disease: a study of 203 cases. Surgery 1999;125:479-483.
207. Lundgren E, Ridefelt P, Äkerström G, Ljunhall S, Rastad J. Parathyroid tissue in normocalcemic and hypercalcemic primary hyperparathyroidism recruited
by health screening. World J Surg 20:727-735, 1996. [PubMed: 8678973]
208. Shen W, Düren M, Morita E, Higgins C, Duh QY, Siperstein AE, Clark OH. Reoperation for persistent or recurrent primary hyperparathyroidism. Arch Surg
131:861-869, 1996. [PubMed: 8712911]
209. Casas AT, Burke GJ, Mansberger AR Jr, Wei JP. Impact of Technetium-99m-sestamibi localization on operative time and success of operations for primary
hyperparathyroidism. Am Surg 1994;60:12. [PubMed: 8273968]
210. Malhotra A, Silver CE, Deshpande V, Freeman LM. Preoperative parathyroid localization with sestamibi. Am J Surg 172:637-640, 1996. [PubMed:
8988666]
211. Martin D, Rosen IB, Ichise M. Evaluation of single isotope technetium 99m-sestamibi in localization efficiency for hyperparathyroidism. Am J Surg
172:633-636, 1996. [PubMed: 8988665]
212. Farr HW, Fahey TJ Jr, Nash AG, Farr CM. Primary hyperparathyroidism and cancer. Am J Surg 1973;126:539. [PubMed: 4743840]
213. DiGiulio W, Morales JO. The value of selnomethionine Se75 scan in preoperative localization of parathyroid adenomas. JAMA 1969;209:1873. [PubMed:
5820075]
214. Bilezikian JP, Doppman JL, Shimkin PM. Preoperative localization of abnormal parathyroid tissue: cumulative experience with venous sampling and
arteriography. Am J Med 1973;55: 505. [PubMed: 4743348]
215. McIntyre RC, Eisenach JH, Pearlman NW, Ridgeway CE, Liechty RD. Intrathyroidal parathyroid glands can be a cause of failed cervical exploration for
hyperparathyroidism. Am J Surg 174:750-754, 1997. [PubMed: 9409611]
216. Libutti SK, Bartlett DL, Jaskowiak NT, Skarulis M, Marx SJ, Spiegel AM, Fraker DL, Doppman JL, Shawker TJ, Alexander HR. The role of thyroid resection
during reoperation for persistent or recurrent hyperparathyroidism. Surgery 122:1183-8, 1997. [PubMed: 9426436]
217. Gray SW, Skandalakis JE, Akin JT Jr, Droulias C, Vohman MD. Parathyroid glands. Am Surg 1976;42:653. [PubMed: 949136]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
120/125
5/24/2014
Print: Chapter 1. Neck
218. Hooghe L, Kinnaert P, Van Geertruyden J. Surgical anatomy of hyperparathyroidism. Acta Chir Belg 1992;92:1. [PubMed: 1553842]
219. Wei JP, Tippins RB, Rao RN, Burke GJ, Mansberger AR Jr. Nonadenomatous thymic unencapsulated parathyroid tissue as a cause of persistent primary
hyperparathyroidism. South Med J 1994;87:1264. [PubMed: 7973927]
220. McHenry CR, Lee K, Saadey J, Neumann DR, Esselstyn Jr CB. Parathyroid localization with technetium-99m-sestamibi: a prospective evaluation. J Am Coll
Surg 183:25-30, 1996. [PubMed: 8673304]
221. Bonjer HJ, Bruining HA, Pols HAP, de Herder WW, Proye CAG, Carnaille BML, Mohammedamin RSA, Steyerberg EW, Breeman WAP, Krenning EP. 2Methoxyisobutylisonitrile probe during parathyroid surgery: tool or gadget? World J Surg 22(6):507-512, 1998.
222. Purcell GP, Dirbas FM, Jeffrey RB, Lane MJ, Desser T, McDougall IR, Weigel RJ. Parathyroid localization with high-resolution ultrasound and technetium Tc
99m sestamibi. Arch Surg 1999;134:824-830. [PubMed: 10443804]
223. Szabo E, Lundgren E, Juhlin C, Ljunghall S, Äkerström G, Rastad J. Double parathyroid adenoma, a clinically nondistinct entity of primary
hyperparathyroidism. World J Surg 22:708-713, 1998. [PubMed: 9606286]
224. Krausz Y, Lebensart PD, Klein M, Weininger J, Blachar A, Chisin R, Shiloni E. Preoperative localization of parathyroid adenoma in patients with
concomitant thyroid nodular disease. World J Surg 2000;24:1573-1578. [PubMed: 11193726]
225. Alveryd A. Parathyroid gland in thyroid surgery. Acta Chir Scand (suppl) 1968;389:1. [PubMed: 5760870]
226. Delattre JF, Flament JB, Palot JP, Pluot M. [Variations in the parathyroid glands. Number, situation and arterial vascularization. Anatomical study and
surgical application]. J Chir (Paris) 1982;119:633. [PubMed: 7153263]
227. Ander S, Johansson K, Smeds S. Blood supply and parathyroid hormone secretion in pathological parathyroid glands. World J Surg 20(5):598-602, 1996.
228. Weber CJ, Russell J, Chryssochoos JT, Hagler M, McGarity WC. Parathyroid hormone content distinguishes true normal parathyroids from parathyroids of
patients with primary hyperparathyroidism. World J Surg 20:1010-1015, 1996. [PubMed: 8798358]
229. Cisneros G, Lara LF, Crock R, Whittier FC. Humoral hypercalcemia of malignancy in squamous cell carcinoma of the skin: parathyroid hormone-related
protein as a cause. South Med J 2001;94:329-331. [PubMed: 11284521]
230. Perez JB, Pazianos AG. Unusual presentation of primary hyperparathyroidism with osteoporosis, hypercalcemia, and normal parathyroid hormone level.
South Med J 2001;94:339-341. [PubMed: 11284524]
231. LiVolsi VA. Invited Commentary. In Luts L, Bergenfelz A, Alumets J, Sundler F. Parathyroid function and histology in patients with parathyroid adenoma:
correlation of clinical and morphologic findings. World J Surg 21:553-563, 1997.
232. Safran D. Functioning parathyroid cyst. South Med J 91(10):978-980, 1998.
233. Traynor S, Adams JR, Andersen P, Everts E, Cohen J. Appropriate timing and velocity of infusion for the selective staining of parathyroid glands by
intravenous methylene blue. Am J Surg 176:15-17, 1998. [PubMed: 9683125]
234. Adams HD. Parathyroid adenoma: problems of diagnosis and localization. Surg Clin North Am 1968;48:483. [PubMed: 5649782]
235. Cady B. Neck exploration for hyperparathyroidism. Surg Clin North Am 1973;53:301. [PubMed: 4693349]
236. McGarity WC, Bostwick J. Technique of parathyroidectomy. Am Surg 1976;42:657. [PubMed: 949137]
237. Edis AJ. Surgical anatomy and technique of neck exploration for primary hyperparathyroidism. Surg Clin North Am 1977;57:495. [PubMed: 867217]
238. Nathaniels EK, Nathaniels AM, Wang C. Mediastinal parathyroid tumors: a clinical and pathological study of 84 cases. Ann Surg 1970;171:165. [PubMed:
5413453]
239. Gupta VK, Yeh KA, Burke GJ, Wei JP. 99m-Technetium sestamibi localized solitary parathyroid adenoma as an indication for limited unilateral surgical
exploration. Am J Surg 1998;176: 409-412. [PubMed: 9874423]
240. Farnebo F, Auer G, Farnebo L-O, Teh BT, Twigg S, Asperblad U, Thompson NW, Grimelius L, Larsson C, Sandelin K. Evaluation of retinoblastoma and Ki67 immunostaining as diagnostic markers of benign and malignant parathyroid disease. World J Surg 1999;23:68-74. [PubMed: 9841766]
241. Ryan JA, Eisenberg B, Pado KM, Lee F. Efficacy of selective unilateral exploration in hyperparathyroidism based on localization tests. Arch Surg 132:886891, 1997. [PubMed: 9267274]
242. Angelos P, Thompson NW, Giordano TJ. Spontaneous vocal cord paresis and return to normocalcemia: an unusual presentation of parathyroid adenoma
with concomitant abscess. Surgery 121(6):704-707, 1997.
243. Richards ML, Thompson NW, Giordano TJ. Spontaneous infarction of a parathyroid adenoma in primary hyperparathyroidism: Case report and literature
review. Contemp Surg 1999; 54:292-296.
244. Dowlatabadi H. Acute fatal parathyroid poisoning associated with necrosis of the parathyroid adenoma prior to death. J Clin Endocrinol 19:1481-1485,
1959. [PubMed: 13817892]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
121/125
5/24/2014
Print: Chapter 1. Neck
245. Billingsley KG, Fraker DL, Doppman JL, Norton JA, Shawker TH, Skarulis MC, Marx SJ, Spiegel AM, Alexander HR. Localization and operative management
of undescended parathyroid adenomas in patients with persistent primary hyperparathyroidism. Surgery 1994;116:982. [PubMed: 7985106]
246. Barry MK, van Heerden JA, Grant CS, Thompson GB, Khosla S. Is familial hyperparathyroidism a unique disease? Surgery 122: 1028-1033, 1997. [PubMed:
9426416]
247. Proye C, Carnaille B, Quievreux J-L, Combemale F, Oudar C, Lecomte-Houcke M. Late outcome of 304 consecutive patients with multiple gland
enlargement in primary hyperparathyroidism treated by conservative surgery. World J Surg 22:526-530, 1998. [PubMed: 9597923]
248. Chen H, Parkerson S, Udelsman R. Parathyroidectomy in the elderly: do the benefits outweigh the risks? World J Surg 22:531-536, 1998. [PubMed:
9597924]
249. Pasieka JL, Parsons LL. Prospective surgical outcome study of relief of symptoms following surgery in patients with primary hyperparathyroidism. World J
Surg 1998;22:513-518. [PubMed: 9597921]
250. Ryan JA, Lee F. Effectiveness and safety of 100 consecutive parathyroidectomies. Am J Surg 173:441-444, 1997. [PubMed: 9168085]
251. Angelos P. An initial experience with radioguided parathyroid surgery. Am J Surg 2000;180:475-478. [PubMed: 11182401]
252. Miccoli P, Bendinelli C, Vignali E, Mazzeo S, Cecchini GM, Pinchera A, Marcocci C. Endoscopic parathyroidectomy: report of an initial experience. Surgery
1998;124:1077-1080. [PubMed: 9854586]
253. Starr FL, DeCresce R, Prinz RA. Use of intraoperative parathyroid hormone measurement does not improve success of bilateral neck exploration for
hyperparathyroidism. Arch Surg 2001;136:536-542. [PubMed: 11343544]
254. Zaraca F, Mazzaferro S, Catarci M, Saputelli A, Alò P, Carboni M. Prospective evaluation of total parathyroidectomy and autotransplantation for the
treatment of secondary hyperparathyroidism. Arch Surg 1999;134:68-72. [PubMed: 9927134]
255. Mollerup CL, Lindewald H. Renal stones and primary hyperparathyroidism: natural history of renal stone disease after successful parathyroidectomy.
World J Surg 1999;23:173-176. [PubMed: 9880427]
256. Caccitolo JA, Farley DR, van Heerden JA, Grant CS, Thompson GB, Sterioff S. The current role of parathyroid cryopreservation and autotransplantation in
parathyroid surgery: an institutional experience. Surgery 122:1062-1067, 1997. [PubMed: 9426420]
257. D'Avanzo A, Parangi S, Morita E, Duh QY, Siperstein AE, Clark OH. Hyperparathyroidism after thyroid surgery and autotransplantation of histologically
normal parathyroid glands. J Am Coll Surg 2000;190:546-552. [PubMed: 10801021]
258. Stojadinovic A, Shriver CD, Casler JD, Gaertner EM, York G, Jaques DP. Endoscopic laser excision of ectopic pyriform sinus parathyroid adenoma. Arch
Surg 133:101-103, 1998. [PubMed: 9438768]
259. Burgess JR, David R, Parameswaran V, Greenaway TM, Shepherd JJ. The outcome of subtotal parathyroidectomy for the treatment of
hyperparathyroidism in multiple endocrine neoplasia type 1. Arch Surg 133:126-129, 1998. [PubMed: 9484721]
260. Kikumori T, Imai T, Tanaka Y, Oiwa M, Mase T, Funahashi H. Parathyroid autotransplantation with total thyroidectomy for thyroid carcinoma: Long-term
follow-up of grafted parathyroid function. Surgery 1999;125:504-508. [PubMed: 10330938]
261. Droulias C, Tzinas S, Harlaftis N, Akin JT Jr, Gray SW, Skandalakis JE. The superior laryngeal nerve. Am Surg 1976;42: 635-638.
262. Skandalakis JE, Gray SW. Anatomical complications of thyroidectomy. Am Surg 42:620, 1976.
263. Hellström J, Ivemark BI. Primary hyperparathyroidism: clinical and structural findings in 138 cases. Acta Chir Scand (Suppl) 294:1, 1962. [PubMed:
11415271]
264. Lo CY, Lam KY. Parathyroid autotransplantation during thyroidectomy. Arch Surg 1999;134:258-260. [PubMed: 10088564]
265. Lo CY, Lam KY. Routine parathyroid autotransplantation during thyroidectomy. Surgery 2001;129:318-323. [PubMed: 11231460]
266. Berger AC, Libutti SK, Bartlett DL, Skarulis MG, Marx SJ, Spiegel AM, Doppman JL, Alexander HR. Heterogeneous gland size in sporadic multiple gland
parathyroid hyperplasia. J Am Coll Surg 1999;188:382-389. [PubMed: 10195722]
267. Bucher U, Reid L. Development of the intrasegmental bronchial tree: the pattern of branching and development of cartilage at various stages in intrauterine life. Thorax 16:207, 1961. [PubMed: 13874265]
268. Bucher U, Reid L. Development of the mucus-secreting elements in human lung. Thorax 16:219, 1961. [PubMed: 13874266]
269. Burch M, Balaji S, Deanfield JE, Sullivan ID. Investigation of vascular compression of the trachea: the complementary roles of barium swallow and
echocardiography. Arch Dis Child 1993;68: 171. [PubMed: 8481037]
270. Dover K, Howdieshell TR, Colborn GL. The dimensions and vascular anatomy of the cricothyroid membrane: relevance to emergent surgical airway
access. Clin Anat 9:291-295, 1996. [PubMed: 8842535]
271. Coln CE, Purdue GF, Hunt JL. Tracheostomy in the young pediatric burn patient. Arch Surg 133:537-539, 1998. [PubMed: 9605917]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
122/125
5/24/2014
Print: Chapter 1. Neck
272. Maipang T, Singha S, Panjapiyakul C, Totemchokchyakarn P. Mediastinal tracheostomy. Am J Surg 171:581-586, 1996. [PubMed: 8678204]
273. Ger R, Evans JT. Tracheostomy: an anatomico-clinical review. Clin Anat 1993;6:337.
274. Silen W, Spieker D. Fatal hemorrhage from the innominate artery after tracheostomy. Ann Surg 1965;162:1005. [PubMed: 5321057]
275. Yang FY, Criado E, Schwartz JA, Keagy BA, Willox BR. Trachea-innominate artery fistula: retrospective comparison of treatment methods. South Med J
1988;81:701-706. [PubMed: 3287639]
276. Takano H, Ihara K, Sato S, Yuki K, Kodamo Y, Nakata M. Tracheo-innominate artery fistula following tracheostomy: successful surgical management of a
case. J Cardiovasc Surg 1989;30:860. [PubMed: 2681221]
277. Weiman DS, Pate JW, Walker WA, Brosnan KM, Fabian TC. Combined gunshot injuries of the trachea and esophagus. World J Surg 20:1096-1100, 1996.
[PubMed: 8798371]
278. Upadhyay A, Maurer J, Turner J, Tiszenkel H, Rosengart T. Elective bedside tracheostomy in the intensive care unit. J Am Coll Surg 182:51-55, 1996.
279. Kirchner JA. Tracheostomy and its problems. Surg Clin North Am 1980;60:1093. [PubMed: 7434153]
280. Artz CP, Hardy JD. Management of Surgical Complications (3rd ed). Philadelphia: Saunders, 1960.
281. Bonanno PC. Swallowing dysfunction after tracheostomy. Ann Surg 1971;174:29. [PubMed: 5092509]
282. Roe BB. Bedside tracheostomy. Surg Gynecol Obstet 1962;115: 239. [PubMed: 14493231]
283. Bouquot JE, Gnepp DR, Dardick I, Hietanen JH. Intraosseous salivary tissue: jawbone examples of choristomas, hamartomas, embryonic rests, and
inflammatory entrapment: another histogenic source for intraosseous adenocarcinoma. Oral Surg Oral Med Oral Path Oral Radiol Endodont 2000;90:205-217.
[PubMed: 10936840]
284. Ha SL, Shin JE, Yoon TH. Salivary gland choristoma of the middle ear: a case report. Am J Otolaryngol 2000;21:127-130. [PubMed: 10759000]
285. Martinez Subias J, Royo Lopez J, Valles Varada H. [Congenital absence of major salivary glands]. Acta Otolaryngol Espanola 2000;51:276-278.
286. Anson BJ, McVay CB. Surgical Anatomy (5th ed). Philadelphia, Saunders, 1971, p. 206.
287. Tostevin PMJ, Ellis H. The buccal pad of fat: a review. Clin Anat 1995;8:403. [PubMed: 8713160]
288. Davis RA, Anson BJ, Budinger JM, Kurth LE. Surgical anatomy of the facial nerve and parotid gland based upon a study of 350 cervicofacial halves. Surg
Gynecol Obstet 1956;102:385. [PubMed: 13311719]
289. Winsten J, Ward GE. The parotid gland: an anatomic study. Surgery 1956;40:585. [PubMed: 13360627]
290. Poncet JL, Rondet P, Kossowski M, Cudennec YF, Buffe P. Surgery of the parotid gland: indications, review of the anatomy. Ann Radiol (Paris)
1991;34:122. [PubMed: 1897845]
291. Marks NJ. The anatomy of the lymph nodes of the parotid gland. Clin Otolaryngol 1984;9:271-275. [PubMed: 6509793]
292. Last RJ. Anatomy: Regional and Applied, 5th Ed. Baltimore: Williams & Wilkins, 1972, p. 602.
293. Lescher TC, Hollinshead WH, ReMine WH. Surgical management of benign parotid disease. Am J Surg 1967;113:545.
294. Hogg SP, Kratz RC. Surgical exposure of the facial nerve. Arch Otol 1958;67:560. [PubMed: 13520028]
295. Purcelli FM. Exposure of the facial nerve in parotid surgery: a study of the use of the tympanomastoid suture as a landmark. Am Surg 1963;29:657.
[PubMed: 14070781]
296. Williams HK, Connor R, Edmondson H. Chronic sclerosing sialadenitis of the submandibular and parotid glands: a report of a case and review of the
literature. Oral Surg Oral Med Oral Path Oral Radiol Endodont 2000;89:720-723. [PubMed: 10846127]
297. Tunkel DE, Loury MC, Fox CH, Goins MA, Johns ME. Bilateral parotid enlargement in HIV-seropositive patients. Laryngoscope 1989;99:590-595. [PubMed:
2725154]
298. James DG, Sharma OP. Parotid gland sarcoidosis. Sarcoidosis Vasculitis Diffuse Lung Dis 2000;17:27-32. [PubMed: 10746259]
299. Kelley DJ, Spiro RH. Management of the neck in parotid carcinoma. Am J Surg 172:695-697, 1996. [PubMed: 8988681]
300. Renehan A, Gleaves EN, McGurk M. An analysis of the treatment of 114 patients with recurrent pleomorphic adenomas of the parotid gland. Am J Surg
172:710-714, 1996. [PubMed: 8988685]
301. Forty MJ, Wake MJ. Pleomorphic salivary adenoma in an adolescent. Br Dent J 2000;10:545-546.
302. McKenna RJ. Tumors of the major and minor salivary glands. CA 1984;34:24. [PubMed: 6420017]
303. North CA, Lee DJ, Piantadosi S, Zahurak M, Johns ME. Carcinoma of the major salivary glands treated by surgery or surgery plus postoperative
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
123/125
5/24/2014
Print: Chapter 1. Neck
303. North CA, Lee DJ, Piantadosi S, Zahurak M, Johns ME. Carcinoma of the major salivary glands treated by surgery or surgery plus postoperative
radiotherapy. Int J Radiat Oncol Biol Phys 1990;18:1319-1326. [PubMed: 2115032]
304. Shikhani AH, Johns ME. Tumors of the major salivary glands in children. Head Neck Surg 1988;10:257-263. [PubMed: 3069812]
305. Johns ME. Parotid cancer: a rational basis for treatment. Head Neck Surg 1980;3:132-144. [PubMed: 7440180]
306. Johns ME, Shikhani AH, Kashima HK, Matanoski GM. Multiple primary neoplasms in patients with salivary gland or thyroid gland tumors. Laryngoscope
1986;96:718-721. [PubMed: 3724320]
307. Shikhani AH, Matanoski GM, Jones MM, Kashima HK, Johns ME. Multiple primary malignancies in head and neck cancer. Arch Otolaryngol 1986;112:11721179. [PubMed: 3755993]
308. Johns ME, Rice DH. Malignant neoplasms of the salivary glands. In: English GM (ed). Otolaryngology. Philadelphia: Harper & Row, 1987, vol 5, p. 1-28.
309. Brenner E, Schoeller T. Masseteric nerve: a possible donor for facial nerve anastomosis? Clin Anat 1998;11:396-400. [PubMed: 9800919]
310. Spira M. Anastomosis of masseteric nerve to lower division of facial nerve for correction of lower facial paralysis. Preliminary report. Plast Reconstr Surg
1978;61:330-334. [PubMed: 625495]
311. Fournier HD, Denis F, Papon X, Hentati N, Mercier P. An anatomical study of the motor distribution of the mandibular nerve for a masseteric-facial
anastomosis to restore facial function. Surg Radiol Anat 19:241-244, 1997. [PubMed: 9381330]
312. Sperber GH. Craniofacial Embryology (4th ed). London: Butterworth, 1989.
313. Ziarah MA, Atkinson ME. The surgical anatomy of the mandibular distribution of the facial nerve. Br J Oral Surg 1981; 19:159. [PubMed: 6945120]
314. Martin H. Surgery of Head and Neck Tumors. New York: Hoeber-Harper, 1957.
315. O'Rahilly R. Gardner-Gray-O'Rahilly Anatomy (5th ed). Philadelphia: WB Saunders, 1986, p. 682.
316. Johns ME, Batsakis JG, Short CD. Oncocytic and oncocytoid tumors of the salivary glands. Laryngoscope 1973;83:1940-1952. [PubMed: 4772101]
317. Paulino AF, Huvos AG. Oncocytic and oncocytoid tumors of the salivary gland. Sem Diagn Pathol 1999;16:98-104. [PubMed: 10452575]
318. Wilson CP. Lateral cysts and fistulas of the neck of developmental origin. Ann R Coll Surg Engl 1955;17:1. [PubMed: 13239046]
319. Kim KH, Sung MW, Koh TY, Oh SH, Kim IS. Pyriform sinus fistula: management with chemocauterization of the internal opening. Ann Otol Rhinol Laryngol
2000;109:452-456. [PubMed: 10823473]
320. Brazilian Head and Neck Cancer Study Group. Results of a prospective trial on elective modified radical classical versus supraomohyoid neck dissection in
the management of oral squamous carcinoma. Am J Surg 1998;176:422-27.
321. Kerth JD, Sisson GA, Becker GD. Radical neck dissection in carcinoma of the head and neck. Surg Clin North Am 1973;53: 179. [PubMed: 4702996]
322. Kierner AC, Aigner M, Zelenka I, Riedl G, Burian M. The blood supply of the sternocleidomastoid muscle and its clinical implications. Arch Surg
1999;134:144-147. [PubMed: 10025452]
323. Carney AL, Anderson EM. Hypoglossal carotid entrapment syndrome. Adv Neurol 1981;30:223. [PubMed: 7304301]
324. Gordon SL, Graham WP III Black JT, Miller SH. Accessory nerve function after surgical procedures in the posterior triangle. Arch Surg 1977;112:264.
[PubMed: 843216]
325. Eisen A, Bertrand G. Isolated accessory nerve palsy of spontaneous origin. Arch Neurol 1972;27:496. [PubMed: 5083867]
326. Bell DS. Pressure palsy of the accessory nerve. Br Med J 1964;1: 1483.
327. Singh S, Schlagenhauff RE. Pressure palsy of accessory nerve. Neurol India 1971;18:122.
328. O'Brien CJ. Modified radical neck dissection: terminology, technique and indications. Am J Surg 1987;153:310. [PubMed: 16453390]
329. Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.
330. Saunders JR Jr, Hirata RM, Jaques DA. Considering the spinal accessory nerve in head and neck surgery. Am J Surg 1985;150: 491. [PubMed: 4051114]
331. Soo KC, Strong EW, Spiro RH, Shah JP, Nori S, Green RF. Innervation of the trapezium muscle by the intra-operative measurement of motor action
potentials. Head Neck 1993;15:216. [PubMed: 8491585]
332. Brown H, Burns S, Kaiser CW. The spinal accessory nerve plexus, the trapezium muscle, and shoulder stabilization after radical neck cancer surgery. Ann
Surg 1988;208:654. [PubMed: 3056289]
333. Zibordi F, Baiocco F, Bascelli C, Bini A, Canepa A. Spinal accessory nerve function following neck dissection. Ann Otol Rhinol Laryngol 1988;97:83.
[PubMed: 3341706]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
124/125
5/24/2014
Print: Chapter 1. Neck
334. King RJ, Motta G. Iatrogenic spinal accessory nerve palsy. Ann R Coll Surg Engl 1983;65:35. [PubMed: 6824298]
335. Donner TR, Kline DG. Extracranial spinal accessory nerve injury. Neurosurgery 1993;32:907. [PubMed: 8392146]
336. Decker GAG, Du Plessis DJ (eds). Lee McGregor's Synopsis of Surgical Anatomy (12th ed). Bristol, England: John Wright, 1986.
337. Southwick HW, Slaughter DP. Neck dissection: complications and safeguards. Surg Clin North Am 35:31-39, 1955.
338. Batson OV. The adult thyroglossal duct. Anat Rec 1946;94:449.
339. Zarem HA. The management of complications in head and neck surgery. Surg Clin North Am 1973;53:191. [PubMed: 4702997]
340. Nussenbaum B, Liu JH, Sinard RJ. Systemic management of chyle fistula: the Southwestern experience and review of the literature. Otolaryngol Head
Neck Surg 2000;122:31-38. [PubMed: 10629479]
341. Gregor RT. Management of chyle fistulization in association with neck dissection. Otolaryngol Head Neck Surg 2000;122:434-439. [PubMed: 10699823]
342. Moore OS, Karlan M, Sigler L. Factors influencing the safety of carotid ligation. Am J Surg 118:666-668, 1969. [PubMed: 5347083]
343. Schmiedek P, Piepgras A, Leinsinger G, Kirsch CM, Einhupl K. Improvement of cerebrovascular reserve capacity by EC-IC arterial bypass surgery in
patients with ICA occlusion and hemodynamic cerebral ischemia. J Neurosurg 81(2):236-244, 1994.
344. Puttini M, Palmieri B, Romani F, Barbano PR, Riolo F, Rimoldi PA. [Carotid stenosis with contralateral occlusion. Surgical indications and results]. (Italian).
Minerva Cardioangiolog 43(3): 81-84, 1995.
345. Richter HP. (Comments) In: Donner TR, Kline DG. Extracranial spinal accessory nerve injury. Neurosurgery 1993;32:907.
346. Gabel G, Nunley JA. Spinal accessory nerve. In: Gelberman RH (ed). Operative Nerve Repair and Reconstruction. Philadelphia: JB Lippincott, 1991, pp.
445-452.
347. Tindall SC. (Comments) In: Donner TR, Kline DG. Extracranial spinal accessory nerve injury. Neurosurgery 1993;32:907.
348. Saffold SH, Wax MK, Nguyen A, Caro JE, Andersen PE, Everts EC, Cohen JI. Sensory changes associated with selective neck dissection. Otolaryngol
Head Neck Surg 2000;126:425-428. [PubMed: 10722022]
349. Brown H, Hidden G, Ledroux M, Poitevan L. Anatomy and blood supply of the lower four cranial and cervical nerves: relevance to surgical neck
dissection. PSEBM 2000;223:352-361. [PubMed: 10721004]
350. Ducic Y, Hilger PA. The use of unilateral deep plane neck lifting to improve the aesthetic appearance of the neck dissection deformity. Am J Otolaryngol
2000;21:202-206.
351. Clark OH, Way LW, Hunt TK. Recurrent hyperparathyroidism. Ann Surg 1976;184:391-399. [PubMed: 1015886]
352. Edis AJ, Beahrs OH, Sheedy PF. Reoperation for hyperparathyroidism. World J Surg 1977;1:731-738. [PubMed: 607591]
353. Martin JK Jr, van Heerden JA, Edis AJ, Dahlin DC. Persistent postoperative hyperparathyroidism. Surg Gynecol Obstet 1980; 151:764-768.
354. Granberg P, Johansson G, Lindvall N, Ohman U, Wajngot A, Werner S. Reoperation for primary hyperparathyroidism. Am J Surg 1982;143:296-300.
[PubMed: 7065348]
355. Satava RM, Beahrs OH, Scholz DA. Success rate of cervical exploration for hyperparathyroidism. Arch Surg 1975;110:625-628. [PubMed: 1131006]
356. Grant CS, van Heerden JA, Charboneau JW, James EM, Reading CC. Clinical management of persistent and/or recurrent primary hyperparathyroidism.
World J Surg 1986;10:555-565. [PubMed: 3529648]
357. Cheung PS, Borgstrom A, Thompson NW. Strategy in reoperative surgery for hyperparathyroidism. Arch Surg 1989;124:676-680. [PubMed: 2730318]
358. Sugg SL, Fraker DL, Alexander HR. Prospective evaluation of selective venous sampling for parathyroid hormone concentration in patients undergoing
reoperation for primary hyperparathyroidism. Surgery 1993;114:1004-1010. [PubMed: 8256203]
359. Rouviere H. Anatomy of the Human Lymphatic System. Tobias MJ (trans). Ann Arbor MI: Edwards Brothers, 1938.
C opyright ©2006 The McGraw-Hill C ompanies. All rights reserved.
Privacy Notice. Any use is subject to the Terms of Use and Notice. Additional C redits and C opyright Information.
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NECK: GENERAL
HISTORY
The anatomic and surgical history of the general neck, thyroid, parathyroids, trachea, and salivary glands is shown in Table 1-1.
Table 1-1. Anatomic and Surgical History of the Neck, Thyroid, Parathyroids, Trachea, and Salivary Glands
Egypt
2780- Statues show signs of Graves' disease
2280
B.C.
India
2000- The Hindu Rig Veda mentions tracheal cannulation
1000
B.C.
China
1600
B.C.
Used burnt sponge and seaweed to treat goiters
Sushruta
600
B.C.
Introduced the nasolabial flap
India
400
B.C.
The Ayur Veda discusses the treatment and diagnosis of goiters
Egypt
69-30 A temple wall engraving shows Cleopatra with goiter
B.C.
Celsus
50-30 Described the appearance and surgery of cystic goiters
B.C.
Galen (ca. 130200 A.D.)
Considered the thyroid a buffer between the heart and the brain. Called the thyroid cartilage thyreos, meaning "oblong shield."
Paul of Aegina
(625-690)
Surgically treated a bronchocele. Attributed parotitis to humoral imbalance in the head (collecting in the parotid gland during fevers, for
example).
Ali-ibn-Abbas
ca.
990
Reported on the surgical treatment of goiters
Abul Casen
Ebn Abbas
(Albucasis)
1050
Treated "elephantiasis" of the throat (goiter) surgically and stopped hemorrhage using Khalaf cautery and ligatures
Wang Hei
1475
Described the thyroid gland while recommending that dried thyroid be used to treat goiter
da Vinci (14521519)
Provided illustrations of the thyroid glands
Paré (1510-
Described the parotid glands as "emunctories of the brain"
1590)
Vesalius
1543
Wrote of and illustrated the "Glandes laryngis radici adnatae" (thyroid glands) in Fabrica
Eustachius
1563
Described the connection point of the two thyroid lobes as an "isthmus"
Severino
(1580-1656)
Performed a tracheotomy to open an obstructed airway. Constructed a trocar to maintain air passage after the procedure.
Casserio
1601
Described the thyroid glands, calling them "the glands of the larynx"
Fabricius
1620
Thought of a goiter as an enlargement of the thyroid glands
Feyens
1649
Performed a tracheotomy, calling it a "bronchotomy"
Wharton
1656
Used the term "thyroid" correctly in his Adenographia. He believed that it served to lubricate, drain, and warm the larynx.
Hesiter (16831758)
Established the term "tracheotomy," and provided the first description of surgical excision of goiter
Von Haller
1743
First to describe a carotid body tumor
Duphenix
1757
Wrote of gustatory sweating in the Memoirs de L'Academie Royale de Chirurgie
Gooch
1773
Reported two thyroidectomies
Von Haller
1776
Classified the thyroid, thymus, and spleen as glands without ducts that release their fluids into the bloodstream
Parry
1786
Offered an original account of exophthalmic goiter
Desault
1791
Reported a successful excision of part of the thyroid
Blizzard
1811
Successfully ligated the superior thyroid arteries, offering another form of thyroidectomy
Coindet
1820
Recommended iodine as a treatment for goiter
Parry
1825
In a posthumously published paper (d. 1822), he first described the effects of "thyrotoxicosis" — now known as Graves' disease (in England)
and Basedow's disease (in Europe)
Graves
1835
Observed and described effects of an overactive thyroid
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Owen
1852
Described the parathyroid gland of a rhinoceros
Buck
1853
Performed a partial laryngectomy
Lushka
1862
Described carotid body tumors in great detail
Czerny
1870
Performed laryngectomies on 5 dogs (4 died)
Gull
1873
Described primary myxedema
Billroth
1873
As reported by Gussenbauer in 1874, he performed a laryngectomy
P. Von Bruns
1878
Argued, "The attempt at radical extirpation of cancer of the larynx by means of thyrotomy has proved itself completely unsatisfactory and
worthless."
Reigner
1880
Attempted excision of a carotid body tumor
Sandström
1880
Described the parathyroid glands, suggesting they were embryonic portions of the thyroid
Rehn
1880
Performed a thyroidectomy to treat exophthalmic goiter
Steida
1881
Described thyroid development
Billroth
1881
Reported 48 thyroidectomies performed since 1877, in which only four patients died. First to use artery forceps to prevent and stop
hemorrhage. Noted the presence of post-surgical tetany in many of his patients.
Kocher
1883
Reported his first 100 thyroidectomies (30 of which were total thyroidectomies). Method involved ligating the thyroid arteries outside the
capsule and the gland with an aneurysm needle, and ligating as close to the carotid artery as possible. Used a transverse collar incision now
bearing his name. Noted the presence of "cachexia stermipriva" or postoperative myxedema in his total thyroidectomy patients.
Born
1885
First used term "lateral thyroid"
Von MikuliczRadecki
1886
Described and performed subtotal thyroidectomy to avoid complications arising from removal of the gland
Maydl
1886
Successfully removed a carotid body tumor. The patient suffered a postoperative stroke, causing hemiplegia and aphasia, and later died.
Horsley
1886
Observed nervous system depression after thyroidectomy in monkeys. Concluded that the thyroid secreted a vital substance.
M. Mackenzie
1887
Opposed total laryngectomy in the case of Emperor Frederick II of Prussia
Von MikuliczRadecki
1888
Reported a case in which the patient experienced sweating involving submandibular (submaxillary) and parotid gland swelling (later named
Mikulicz' disease)
Albert
1889
Successfully removed a carotid body tumor without postoperative stroke
Von
Recklinhausen
1891
Observed and described osteitis fibrosa cystica in hyperparathyroidism
Gley
1891
Described tetany following removal of the parathyroid glands during thyroidectomy
Kocher
1895
Reported 900 cases of thyroidectomy with a mortality rate slightly higher than 1%. Avoided total thyroidectomies whenever possible.
1898
Reported an additional 600 thyroidectomies with only 1 operative death (caused by anesthesia).
Vassale and
Generali
1896
Introduced the term "parathyroid"
Butlin
1900
Advocated clearing out the anterior triangle of the neck (especially its lymphatic component) to combat the spread of metastatic disease from
the tongue
Loeb
1901
Observed occurrence of tetany in frog muscle deprived of calcium
M. Askanazy
1903
Hypothesized on the relation between parathyroid tumors and osteitis fibrosa cystica
C. Mayo
1904
Presented a paper on thyroid surgery to the American Surgical Association. Reported 40 cases of Graves' disease that were treated by
thyroidectomy.
Erdheim
1906
Studied the relationship between parathyroid glands and calcium metabolism, noting compensatory hypertrophy and osteomalacia
Halsted
1906
Provided dietary supplements of parathyroid glands from cattle to confront clinical tetany. Experimented with transplantation of the
parathyroids.
Crile
1906
Reported on 132 cases in which he performed a radical neck excision. Procedure included en-bloc resection of the regional lymph nodes,
sternocleidomastoid muscle, internal jugular vein, and submandibular (submaxillary) salivary gland.
C. Mayo
1907
First to use the term "hyperthyroidism"
MacCallum and 1908
Voegtlin
Studied hypoparathyroidism and its relation to low serum calcium. Found that injecting calcium relieved tetany.
C. Jackson
1909
Performed the first modern tracheostomy
C. Mayo
1912
Operated on 278 patients with exophthalmic goiter without a death. Recommended the division of the strap muscles for adequate exposure
(visualization of the recurrent laryngeal nerve) and for the preservation of the parathyroids to decrease the risk of tetany.
Kendall
1914
Isolated thyroxine
Schlagenhaufer 1915
Found that a tumor, not compensatory hypertrophy, is present in osteitis fibrosa cystica. Recommended the excision of parathyroid tumors.
Lipsztat
1922
Observed gustatory sweating near the parotid gland
L. Frey
1923
Published article on auriculotemporal nerve syndrome involving the parotid gland. The disease was later named Frey's syndrome.
Hanson
1924
Extracted parathyroid hormone
Mandl
1925
Removed a parathyroid adenoma
Harington
1926
Determined the chemical structure of thyroxine
Collip
1926
Linked hyperparathyroidism to elevated serum calcium (also isolated parathyroid hormone in 1925)
DuBois
1926
Removed a parathyroid adenoma – finally found in the mediastinum after seven previous explorations – in a patient with osteitis fibrosa
cystica due to hyperparathyroidism
Harington and
Barger
1927
Synthesized thyroxine
Weller
1933
Believed that 3 primordia are responsible for thyroid genesis ("lateral thyroid primordium")
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Gilmour
1938
Published his studies on the gross and histological anatomy of the parathyroid glands
Hyde
1944
Reported on the total removal of a cervical thymic cyst
Ramsay
1950
Transplanted and cultured the 4th pharyngeal apparatus; was not able to produce thyroid tissue, but produced parathyroid and thymic tissue
Wendlet
1950
Synthesized cortisol
Martin
1951
Published Neck Dissection, which outlined his experiences with prophylactic neck dissection as a treatment for cervical cancer
Gross and Pitt- 1953
Rivers
Extracted triiodothyronine from the thyroid gland. Later synthesized it as liothyronine.
Redon
1955
Published his classic report on the surgery of the salivary glands
Martin
1957
Published his classic work, Surgery of Head and Neck Tumors
Patey,
Thackray, and
Keeling
1965
Published an extensive report describing the behavior of salivary gland tumors and their treatment
Pearse
1966
Renamed the interfollicular cells the "C" cells because of their calcitonin-producing properties
Toye and
Weinstein
1969
Established the concept of minimally invasive airway access for surgery
Beahrs
1977
Detailed technique and surgical anatomy of radical neck dissection
Conley and
Clairmont
1977
Described the use of the scapula flap for reconstruction
Futrell et al.
1978
Described platysma myocutaneous flap use in neck reconstruction
Ariyan
1979
Described the use of the pectoralis major myocutaneous flap in neck reconstruction
Panje et al.
1987
Described gastroomental flap use in neck reconstruction
Gaz
1987
Noted the unusual location of parathyroid glands in surgical patients
History table compiled by David A. McClusky III and John E. Skandalakis.
References:
Albright F. A page out of the history of hyperparathyroidism. J Clin Endocrinol 1948;8:637-657.
Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63:73-81.
Beahrs OH. The surgical anatomy and technique of parotidectomy. Surg Clin North Am 1977;57:477.
Beahrs OH. Presidential Address: Lest we forget. Surgery 1987;102:893-897.
Becker WF. Presidential Address: Pioneers in thyroid surgery. Ann Surg 1977;185:493-504.
Burton MJ, Brochwicz-Lewinski M. Lucja Frey and the auriculotemporal nerve syndrome. J Roy Soc Med 1991;84:619-620.
Cady B. History of thyroid and parathyroid surgery. In: Cady B, Rossi RL (eds). Surgery of the Thyroid and Parathyroid Glands (3rd ed). Philadelphia: W.B. Saunders,
1991. pp. 1-4.
Colcock BP. Lest we forget: A story of five surgeons. Surgery 1968;64:1162-1171.
Conley JJ, Clairmont AA Jr. Regional flaps in ablative surgery in the head and neck. Am Fam Physician 1977;15:100-105.
Futrell JW, Johns ME, Edgerton MT, Cantrell RW, Fitz-Hugh GS. Platysma myocutaneous flap for intraoral reconstruction. Am J Surg 1978;136:504-507.
Givel JC. Historical review. In: Givel JC (ed). Surgery of the Thymus: Pathology, Associated Disorders and Surgical Technique. Berlin: Springer-Verlag, 1990, pp. 1-8.
Gray SW, Skandalakis JE, Akin JT Jr, Droulias C, Vohman MD. Parathyroid glands. Am Surg 42(9):653-656, 1976.
Ioannides C, Fossion E. Nasolabial flap for the reconstruction of defects of the floor of the mouth. Int J Oral Maxillofac Surg 1991;20:40-43.
Liapis C, Gougoulakis A, Karydakis V, Verikokos C, Doussaitou B, Skandalakis P, Gogas J, Sechas M. Changing trends in management of carotid body tumors. Am Surg
1995;61:989-993.
McIntosh D. Surgical interests in some anomalies of the cervical viscera. J R Coll Surg Edinburgh 1979;24(4):191-204.
Martin H. Surgery of Head and Neck Tumors. New York: Hoeber-Harper, 1957, pp. 3-13.
Martin H, Valle BD, Ehrlich H, Cahan WG. Neck dissection. Cancer 1951;4:441-499.
Nelson WR. In search of the first head and neck surgeon. Am J Surg 1978;154:342-346.
Pahor AL. Historical article: Ear, nose and throat in ancient Egypt. J Laryngol Otol 106:863-873, 1992.
Panje WR, Little AG, Moran WJ, Ferguson MK, Scher N. Immediate free gastro-omental flap reconstruction of the mouth and throat. Ann Otol Rhinol Laryngol
1987;96:15-21.
Ramsay AJ. Experimental studies on the developmental potentialities of the third pharyngeal pouch in the mammalian embryo (mouse). Anat Rec 1950;106-234.
Schwartz SI. Little glands, big names (editorial). Contemp Surg 1993;42:402.
Wilkins EW Jr. Thymoma. In: Pearson FG, Deslauriers J, Hiebert CA, McKneally MF, Ginsberg RJ, Urschel HC (eds). Thoracic Surgery. New York: Churchill Livingstone,
1995, p. 1419.
Wilkins EW Jr. Thymectomy. In: Pearson FG, Deslauriers J, Hiebert CA, McKneally MF, Ginsberg RJ, Urschel HC (eds). Thoracic Surgery. New York: Churchill Livingstone,
1995, p. 1483.
EMBRYOGENESIS OF THE NECK
Normal Development
The neck, as seen in the adult human, does not exist in the embryo. The embryogenesis of the region is that of the organs contained within it: chiefly the
pharynx and its derivatives, the thyroid, parathyroid, and thymus gland (the last is also considered part of the superior mediastinum). In addition, vessels
passing through the neck from the head to the thorax are elongated and modified during the course of development.
The pharynx elongates at 5 weeks and the esophagus elongates later. After the diaphragm has descended, these three structures separate the head of the
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The pharynx elongates at 5 weeks and the esophagus elongates later. After the diaphragm has descended, these three structures separate the head of the
developing embryo from the relatively large heart. By 7 weeks, a neck is visible (Fig. 1-1). Further details of differentiation and migration will be discussed in
the chapters on the specific organs.
Fig. 1-1.
The development of the neck. A, Fifth week. Prominent branchial arches mark the site of the neck. B, Seventh week. Branchial arches are reduced, a constriction
appears between head and thorax. C, Twelfth week. From this stage on, the true neck is present. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical
Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
We present a very brief description of the pharyngeal apparatus to help the student understand clinically applicable accounts of the autogenic origin of the
many anatomic entities of the neck, as well as their phylogenetic significance. The embryonic pharynx consists of a lateral branchial apparatus on each side,
and the unpaired ventral floor between them. Each lateral branchial apparatus is formed by endodermal pouches, ectodermal branchial clefts, mesodermal
branchial arches, and branchial membranes (closing plates).
The unpaired floor is of endodermal origin and produces the tongue, thyroid gland, larynx, and trachea. The embryogenesis of the four arches starts in the
fourth and fifth weeks. They are marked externally by the four ectodermal branchial or pharyngeal clefts on each side. At the same time, the pharyngeal
pouches develop internally. Characteristically, they do not communicate with the clefts.
The bridges between the arches are the branchial membranes, or closing plates, which are formed by the ectoderm and endoderm (Figs. 1-2, 1-3).
Fig. 1-2.
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Drawings illustrating the human branchial apparatus. A, Dorsal view of the cranial part of an early embryo. B to D, Lateral views, showing later development of the
branchial arches. E to G, Facial views, illustrating the relationship of the first arch to the stomodeum or primitive mouth. H, Transverse section through the cranial
region of an embryo, illustrating the branchial arch components and the floor of the primitive pharynx. I, Horizontal section through the cranial region of an embryo,
illustrating the branchial arch components and the floor of the primitive pharynx. Each arch contains a cartilaginous component, a nerve, an artery, and a muscular
component. J, Sagittal section of the upper region of an embryo, illustrating the openings of the pharyngeal pouches in the lateral wall of the primitive pharynx.
(Based on Moore KL. The Developing Human: Clinically Oriented Embryology. Philadelphia: WB Saunders, 1973.)
Fig. 1-3.
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Branchial grooves, branchial arches, pharyngeal pouches, and closing plates. (Modified from Brantigan OC. Clinical Anatomy. New York: McGraw-Hill, 1963; with
permission.)
Remember
All pharyngeal grooves (clefts) disappear except the first one, which remains as the external auditory canal (external auditory meatus).
All the pharyngeal membranes (closing plates) disappear except the first one, which remains as the tympanic membrane (eardrum).
The pharyngeal arches:
– The first (mandibular) pharyngeal arch is responsible for the embryogenesis of the muscles of mastication, the upper and lower jaws, and the cheek and lower
eyelids. Innervation is by the mandibular branch of the trigeminal nerve (V), and its blood supply is from the facial artery.
– The second (hyoid) pharyngeal arch is responsible for the embryogenesis of the muscle of facial expression and for the styloid process, stylohyoid muscle,
stylohyoid ligament, part of the hyoid bone, the stapes and stapedius muscle, and the posterior belly of the digastric muscle. Its nerve is the facial (VII), and its
artery is the external carotid.
– The only muscle thought to be derived from the third (thyrohyoid or glossopharyngeal) pharyngeal arch is the stylopharyngeus. It is innervated by the
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glossopharyngeal nerve. The artery is the common carotid.
– The fourth pharyngeal arch is unnamed. It is responsible for the embryogenesis of the cricothyroid muscle of the larynx. Its nerve is the superior laryngeal branch
of the vagus nerve.
– For all practical purposes, the fifth arch does not exist.
– The sixth arch fuses with the fourth for the formation of the laryngeal cartilages, thyroid cartilage, and perhaps the aortic arch, right subclavian artery, pulmonary
arteries, and ductus arteriosus. Mesoderm of the sixth arch is responsible for the embryogenesis of the pharyngeal constrictors, pharyngeal muscles, and the
laryngeal muscles. Its nerve is the recurrent branch of the vagus nerve.
The pharyngeal pouches:
– The first pharyngeal pouch is responsible for the embryogenesis of the eustachian tube, tympanic cavity, mastoid antrum (about 9th month of gestation), and
mastoid air cells (about 2 years of age). Small benign growths called cholesteatoma 2 in the form of thickenings of the endodermal lining of the middle ear develop
and are said to commonly cause hearing losses. While their origin is not fully understood, it is believed that they form normally in all embryos, but occasionally some
persist and proliferate to form these growths.
– The second pharyngeal pouch produces the palatine tonsils and the tonsillar fossa. Note: A persisting second plate opening can appear as a branchial cleft sinus,
notoriously open into the tonsillar fossa.
– The third pharyngeal pouch: the dorsal part is responsible for the genesis of the lower parathyroids (parathyroids III); the ventral part for the thymus. In the adult
pharynx, the piriform recess is the site of the third pouch.
– The fourth pharyngeal pouch: the dorsal part is responsible for the genesis of the upper parathyroids (parathyroids IV); the ventral part may be involved with a
small amount of thymic tissue and with the ultimobranchial body.
– For all practical purposes, the fifth pharyngeal pouch, like the fifth pharyngeal arch, does not exist.
Congenital Anomalies
Fistulas, external and internal sinuses, and cysts are the result of obliteration of pharyngeal clefts and pouches. Thymic and parathyroid deficiencies (e.g.,
DiGeorge syndrome) are secondary to partial or total agenesis of the parathyroid and thymus glands.
Neck hygromas are congenital malformations of the lymphatic system of the neck. Gidvani and Bhowmick3 indicated that cystic hygromas are common
congenital neck masses, tend to develop in the left posterior triangle, and appear early in life. The authors reported the case of a posterior cervical midline
cystic hygroma.
Remember
Most pharyngeal fistulas and cysts originate from the second pharyngeal pouch and cleft.
Fistulas of the second pouch open at the lower one-third of the medial border of the sternocleidomastoid (SCM) muscle.
Anomalies of the first cleft are related to the facial nerve.
A pharyngeal sinus or fistula typically travels from the pharyngeal wall, between the internal and external carotid arteries, to reach the skin. In 1993, Miller and
Cohn 4 presented the 31st report of a fourth branchial pouch sinus.
SURGICAL ANATOMY
Surface Anatomy
Landmarks
The most prominent landmarks of the surface anatomy of the neck, especially in males, are as follows:
The sternocleidomastoid muscle separates the anterior part of the neck (anterior triangle) from the posterior part of the neck (posterior triangle).
In males with well-developed musculature, the lateral portion of the trapezius muscle produces much of the fullness of the gentle curve that joins the lateral
posterior part of the neck with the shoulder region. The anterior tuberosity of the transverse process of the sixth cervical vertebra (carotid tubercle of Chassaignac) is
located at the medial border of the sternocleidomastoid and at the level of the cricoid cartilage. Pressure at this point will compress the common carotid artery.
In the midline, from above downward, the following landmarks are noted:
– The most prominent midline feature and the most readily palpated is the thyroid cartilage, the "Adam's apple," which is especially prominent in post-pubertal males.
It is located between the third and fifth cervical vertebrae. The bifurcation of the common carotid artery is located on the horizontal plane at this level. Variations in
the site of division of the carotid artery will always be located above this point.
– The body of the hyoid bone can be palpated at about 1.5 cm above the thyroid cartilage at the level of the third cervical vertebra. (Note: At the midpoint of a line
between the mastoid process and the thyroid prominence, the greater horn of the hyoid bone can be palpated laterally.)
– The arch of the cricoid cartilage is palpable just inferior to the thyroid cartilage. The cricoid cartilage forms the only complete cartilaginous ring around the airway,
something that is not observed with the other cartilages of the respiratory system.
– The cricoid cartilage is located at the level of the sixth cervical vertebra.
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– The cricoid cartilage is located at the level of the sixth cervical vertebra.
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A horizontal plane approximately at the junction of the sixth and seventh cervical vertebrae can be associated with the following anatomic entities (Figs. 1-4, 1-5, 16, and 1-7):
– pharyngoesophageal junction
– laryngotracheal junction
– inferior thyroid artery (which is ventral to the middle cervical ganglion), and then (in order), the carotid sheath, and the omohyoid muscle
– entrance of the inferior laryngeal nerve (recurrent nerve) into the larynx
– entrance of the vertebral artery into the transverse foramen of the sixth cervical vertebra and, slightly more inferiorly, the stellate ganglion
– thyroid isthmus and the greatest height of the thoracic duct, which are located at the level of the seventh cervical vertebra
Fig. 1-4.
The third cervical vertebra is at the level of the hyoid bone; the fourth and fifth cervical vertebrae are at the level of the thyroid cartilage. (Modified from Brantigan
OC. Clinical Anatomy. New York: McGraw-Hill, 1963; with permission.)
Fig. 1-5.
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Sixth cervical vertebra. (Modified from Brantigan OC. Clinical Anatomy. New York: McGraw-Hill, 1963; with permission.)
Fig. 1-6.
Seventh cervical vertebra. (Modified from Brantigan OC. Clinical Anatomy. New York: McGraw-Hill, 1963; with permission.)
Fig. 1-7.
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Diagrammatic cross section through the neck below the hyoid bone showing the layers of the deep cervical fascia and the structures that they envelop. (Modified
from Skandalakis JE, Gray SW, Skandalakis LJ. Surgical anatomy of the oesophagus. In: Jamieson GG (ed). Surgery of the Oesophagus. Edinburgh: Churchill
Livingstone, 1988; with permission.)
Surgical Applications
The consistency of cervical skin changes with age. Hyperextension of the neck will give a better appreciation of the topography of the underlying structures in
relation to the skin.
The surgeon selects the proper incision and its placement in relation to the underlying pathology. The orientation of the connective tissues of the dermis
creates lines of tension in the skin, known as the lines of Langer, which are associated with skin creases of the body. Generally speaking, the transverse
incision is cosmetically superior to the vertical, since crossing the normal skin lines will produce a more prominent scar.
However, the vertical lines produce excellent exposure for surgery of the arteries. Most of the commonly used incisions in the neck are presented in Figures
1-8 and 1-9. Combinations of vertical and transverse incisions can be used, if necessary. Remember, a superiorly-based apron flap should be used for neck
dissection. Close the edges of the divided platysma muscle carefully, and reapproximate the margins of the skin incision meticulously to lessen the likelihood
of unsightly scarring from tension upon the skin.
Fig. 1-8.
Proper placement of incisions in the neck paralleling the normal lines and creases of the skin. A, Excision of congenital sinus: partial mobilization here and lower
segment at B1 . B, Excision of carotid tumor or branchial cleft cyst. C, Diverticulum of esophagus. D, Scalenotomy or phrenic nerve interruption. E, Drainage of
submental abscess. F, Excision of thyroglossal cyst or sinus. G, Cricothyreotomy. H, Tracheotomy. I, Thyroidectomy. J, Drainage of cervical abscess at angle of jaw.
K, Exposure of internal or external carotid arteries. L, Exposure of common carotid artery. M, Exposure of brachial plexus or subclavian artery. (Modified from Anson
BJ, McVay CB. Surgical Anatomy (5th ed). Philadelphia, Saunders, 1971; with permission.)
Fig. 1-9.
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Selected incisions used for classic radical neck dissection. A, Attie. B, Eckers and Byer. C, MacFee. D, Morestin. E, Conley. F, Latyshevsky and Freund. G, Martin. H, Z.
I, Barbosa. (Modified from Strong EW. Radical neck dissection. In Nyhus LM, Baker RJ (eds). Mastery of Surgery, 2nd Ed. Boston: Little, Brown, 1992; with
permission.)
Roon and Christensen 5 subdivided the areas of the neck into three regions with respect to injuries:
– High (above the angle of the mandible)
– Middle (between the angle and the bottom of the cricoid cartilage)
– Low (below the cricoid cartilage)
Surgeons continue to use Roon and Christensen's classification, but they now refer to zones (Fig. 1-10): Zone I is the area Roon and Christensen called
"low"; Zone II, middle; Zone III, high.
Fig. 1-10.
Zones of the neck. The junction of zones I and II is variously described as being at the cricoid cartilage or at the top of the clavicles. The important implication of a
zone I injury is the greater potential for intrathoracic great vessel injury. (Modified from Jurkovich GJ. Definitive care phase: neck injuries. In Greenfield LJ (ed).
Surgery: Scientific Principles and Practice (2nd ed). Philadelphia: Lippincott-Raven, 1997, pp. 309-317; with permission.)
In the same study cited above, Roon and Christensen stated correctly, from an anatomic standpoint, that either high or low injuries can involve vessels
where proximal and distal control is difficult. They advised immediate exploration.
Roden and Pomerantz 6 also advised early operation (neck exploration) for penetrating wounds of the neck. However, Atteberry et al.7 found physical examination
alone to be safe and accurate for evaluation of vascular penetrating injuries in zone II of the neck.
However, Biffl et al.8 stated that selective management of penetrating neck injuries is safe and does not require routine diagnostic testing for asymptomatic
patients with injuries in zones II and III.
We quote from Bumpous et al.9 on penetrating injuries of the visceral compartment of the neck:
Zone II of the anterior neck was the most commonly injured area, with the trachea (69%), esophagus (38%), and larynx (31%) the most commonly
injured structures. Although 31% underwent angiograms, only 13% showed vascular injuries. Eighty-one percent of the patients had injuries involving
more than 1 major structure of the neck. Neck exploration was performed in 81% of the patients and tracheostomies in 75% as well as repair of the
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more than 1 major structure of the neck. Neck exploration was performed in 81% of the patients and tracheostomies in 75% as well as repair of the
trachea (50%), larynx (31%), and esophagus (38%). There is significant mortality associated with these injuries...and many of the patients have longterm sequelae such as dysphagia, hoarseness, and prolonged tracheostomy.
For the evaluation of penetrating neck injuries, Demetriades et al.10 concluded that physical examination and color-flow Doppler imaging are the diagnostic
tools of choice for the physician. They presented an algorithm for the evaluation of these injuries (Fig. 1-11).
Fig. 1-11.
Algorithm for evaluation of penetrating neck injuries. (From Demetriades D, Theodorou D, Cornwell E, Berne TV, Asensio J, Belzberg H, Velmahos G, Weaver F, Yellin
A. Evaluation of penetrating injuries of the neck: prospective study of 223 patients. World J Surg 1997;21:41-48; with permission.)
Britt and Cole11 recommend a paradigm for penetrating neck injuries (Fig. 1-12).
Fig. 1-12.
Penetrating neck injuries management guideline. GSW, gunshot wound; SW, stab wound; HVI, high-velocity injury; *, controversial approach. (From Britt LD, Cole FJ.
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Penetrating neck injuries management guideline. GSW, gunshot wound; SW, stab wound; HVI, high-velocity injury; *, controversial approach. (From Britt LD, Cole FJ.
"Alternative" surgery in trauma management. Arch Surg 1998, 133:1177-1181; with permission.)
Topographic Anatomy of the Neck
The topography of the neck lends itself to description by using a series of natural triangular areas, beginning with the division of the neck into anterior and
posterior cervical triangles, and then by division of these into smaller triangular regions.
The Anterior Cervical Triangle
BOUNDARIES
The boundaries are:
Lateral: sternocleidomastoid muscle
Superior: inferior border of the mandible
Medial: anterior midline of the neck
This large triangle may be subdivided into four more triangles: the submandibular, carotid, muscular, and submental (Fig. 1-13).
Fig. 1-13.
The anterior triangle of the neck is divided into four smaller triangles by the digastric and omohyoid muscles. SCM, sternocleidomastoid muscle. (Modified from
Skandalakis JE, Gray SW, Rowe JS Jr. Surgical anatomy of the submandibular triangle. Am Surg 1979;45:590-596; with permission.)
SUBMANDIBULAR TRIANGLE
The submandibular triangle is demarcated by the inferior border of the mandible above and the anterior and posterior bellies of the digastric muscle below.
Sarikcioglu et al.12 reported an anomalous digastric muscle with three accessory bellies and one fibrous band (Fig. 1-14).
Fig. 1-14.
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Schematic drawing of an anatomic anomaly. 1, anterior belly of digastric muscle; 2, posterior belly of digastric muscle; 3, accessory belly; 4, fibrous band. (Modified
from Sarikcioglu L, Demir S, Oguz N, Sindel M. Anomalous digastric muscle with three accessory bellies and one fibrous band. Surg Radiol Anat 1998;20:453-454; with
permission.)
The largest structure in the triangle, and the most frequent object of the surgeon's attention, is the submandibular salivary gland. Near the end of the sixth
week (slightly later than the parotid gland), it develops from the oral ectoderm. It forms as a solid primordium, becoming canalized later.
Several vessels, nerves, and muscles also are found in the triangle. For the surgeon, the contents of the triangle are best described in four layers, or surgical
planes, starting from the skin. It must be noted that severe inflammation of the submandibular gland can destroy all traces of normal anatomy. In such
instances, identifying and sparing the essential nerves becomes a great challenge.
First Surgical Plane: The Roof of the Submandibular Triangle
The roof of the submandibular triangle is composed of skin, superficial fascia enclosing the platysma muscle and fat, and the underlying mandibular and
cervical branches of the facial nerve (VII) (Fig. 1-15). The mandibular and cervical branches of the facial nerve arise from the cervicofacial division of the
facial nerve. This, the lower division of the facial nerve, passes lateral to the retromandibular (posterior facial) vein within the substance of the parotid gland
in more than 90% of cases;13 in others, it passes medial to the vein. A line drawn from the intertragic notch of the ear, intersecting the midpoint of a line
between the angle of the mandible and the lowest part of the ear, will lie close to the position of the cervicofacial division of the facial nerve.
Fig. 1-15.
The first surgical plane of the submandibular triangle. The platysma lies over the mandibular and cervical branches of the facial nerve. (Modified from Skandalakis JE,
Gray SW, Rowe JS Jr. Surgical anatomy of the submandibular triangle. Am Surg 1979;45:590-596; with permission.)
Remember
The skin should be incised 4 to 5 cm below the mandibular angle.
The platysma and fat compose the superficial fascia.
The mandibular (or marginal mandibular) branch of the facial nerve (VII) lies just below the angle, superficial to the facial artery. Savary et al.14 after studying 10
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The mandibular (or marginal mandibular) branch of the facial nerve (VII) lies just below the angle, superficial to the facial artery. Savary et al.14 after studying 10
fresh cadavers and 1 embalmed cadaver, found several marginal branches, particularly the intermediate ramus, which can form a neural plexus around the facial
artery. Basar et al.15 reported that the marginal mandibular branch of the facial nerve was single in 14 facial halves, consisted of two major branches in 24 facial
halves, and had multiple major branches in 2 halves.
Cervicofacial Division of the Facial Nerve. The nomenclature and topography of the branches of the facial nerve are confusing and variable. The mandibular
(marginal mandibular) nerve is usually the first branch of the cervicofacial division of the facial nerve. In all individuals, this branch crosses superficial to the
facial vein within 2 cm beneath the angular notch of the mandible, wherein the facial vessels can be palpated. From this position it ascends toward the angle
of the lips so that anterior to the position of the facial artery it crosses the lower border of the mandible to supply the muscles of the corner of the mouth
and lower lip.
The curved course of this nerve and the similarly shaped courses of other nerves in this region have led to the term "neural hammocks." The mandibular nerve
forms the first of such hammocks of the submandibular triangle. Skandalakis et al. saw this hammock hanging so far below the mandible that a high
transverse incision would have severed it.16
The mandibular branch of the facial nerve always passes posterior to the angle of the mandible. It lies between the platysma and the deep cervical fascia
(general investing layer), and proceeds to supply the quadratus labii inferioris muscle.
The cervical branch of the facial nerve divides to form descending and anterior branches. The descending branch innervates the platysma and communicates
with the transverse cervical (C2, C3) and great auricular (C2, C3) cutaneous nerves of the neck. The anterior branch, the ramus coli mandibularis, crosses
the mandible superficial to the facial artery and vein, and joins the mandibular branch to contribute to the innervation of the muscles of the lower lip. This
anterior branch forms the second neural hammock of the triangle. It is frequently confused with the mandibular hammock.
Injury to the mandibular branch of the facial nerve results in a very slight drooping of the corner of the mouth. The drooping is not noticeable when the
mouth is in repose –only when it is in motion (smiling). Depending on the nature of the injury, the drooping may be neuropraxia or permanent. Remember that
the orbicularis oris and the muscles innervated by buccal branches actually raise the commissure on the affected side. Injury to the anterior cervical branch
produces minimal drooling that will disappear in 4 to 6 months.
Skandalakis et al.16 measured the distance between these two neural hammocks and the lower border of the mandible in 40 cadavers (80 cervicofacial
dissections). These measurements are shown in Fig. 1-16. In 50 percent of the specimens, the mandibular branch was above the mandibular border and thus
outside the boundaries of the submandibular triangle. In a similar study, Dingman and Grabb17 found the branch to be above the border in 81 percent of their
specimens. If the skin incision is placed at least 4 cm below the border of the mandible, even an exceptionally low cervical branch will not be accidentally
cut.
Fig. 1-16.
The neural "hammocks" formed by the mandibular branch (upper) and the anterior ramus of the cervical branch (lower) of the facial nerve. The distance below the
mandible is given in centimeters. Percentages indicate the frequency of the configuration in 80 dissections of these nerves. (From Skandalakis JE, Gray SW, Rowe JS
Jr. Surgical anatomy of the submandibular triangle. Am Surg 1979;45:590-596; with permission.)
A study of Chinese adults demonstrated that in 67% the marginal mandibular branch ran above the lower border of the mandible, suggesting the existence of
ethnic variations in the topography of the nerve branches.18
Second Surgical Plane: The Contents of the Submandibular Triangle
The structures of the second surgical plane, from superficial to deep, are the facial (anterior facial) vein, the retromandibular (posterior facial) vein, part of
the facial (external maxillary) artery, the submental branch of the facial artery, the superficial layer of submaxillary fascia (deep cervical fascia), the lymph
nodes, the deep layer of submaxillary fascia (deep cervical fascia), and the hypoglossal nerve (XII) (Fig. 1-17).
Fig. 1-17.
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The second surgical plane of the submandibular triangle. The superficial portion of the gland is exposed. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Surgical
anatomy of the submandibular triangle. Am Surg 1979;45:590-596; with permission.)
The retromandibular vein, formed by the union of the superficial temporal and maxillary veins, divides near the angle of the mandible into anterior and
posterior divisions. The posterior division joins the posterior auricular vein to form the external jugular vein. The anterior division passes forward to join the
facial vein, which is inferior to the mandibular notch, thereby forming the common facial vein.13
It is necessary to remember that the facial artery pierces the stylomandibular ligament. This ligament, which most often is thick but sometimes is thin,
extends from the styloid process to the angle of the mandible, with occasional extensions to the stylohyoid muscle and the posterior belly of the digastric
muscle. The ligament is a particularly thickened portion of the deep layer of the fascial capsule of the parotid, which is derived from the superficial investing
lamina of the deep fascia of the neck; it separates the parotid and submandibular glands. Jovanovic 19 described this ligament, emphasizing its importance in
clinical and surgical anatomy. It must be ligated before it is cut to prevent bleeding after retraction. Also, it is important to remember that the lymph nodes
lie within the envelope of the submandibular fascia, in close relationship with the gland, and that nodes occur along facial vessels (this is important in treating
metastatic skin cancers). Differentiation between glands and lymph nodes may be difficult.
The facial vein and the anterior division of the retromandibular vein cross the triangle in front of the submandibular gland, and unite close to the angle of the
mandible to form the common facial vein. The common facial vein empties into the internal jugular vein near the greater cornu of the hyoid bone. It is wise to
identify, isolate, clamp, and ligate both the facial vein and the anterior division of the retromandibular vein.
The facial artery, a branch of the external carotid artery, enters the submandibular triangle under the posterior belly of the digastric muscle and under the
stylohyoid muscle. At its entrance into the triangle, it is under the submandibular gland. After crossing the gland posteriorly, the artery passes over the
mandible, always lying under the platysma. It can be ligated easily.
Third Surgical Plane: The Floor of the Submandibular Triangle
The structures of the third surgical plane, from superficial to deep, include the mylohyoid muscle with its nerve, the hyoglossus muscle, the middle constrictor
muscle covering the lower part of the superior constrictor muscle, and part of the styloglossus muscle (Fig. 1-18).
Fig. 1-18.
The third surgical plane of the submandibular triangle. The superficial portion of the gland has been removed and the deep portion is visible under the edge of the
mylohyoid muscle. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Surgical anatomy of the submandibular triangle. Am Surg 1979;45:590-596; with permission.)
Mylohyoid Muscle. According to DuPlessis,20 the mylohyoid muscles are considered to form a true diaphragm for the floor of the mouth, with the geniohyoid
muscle and the muscles of the tongue above, and the anterior bellies of the digastric muscles and a major portion of the submandibular gland below. The
mylohyoid arises from the mylohyoid line of the inner surface of the mandible; its more posterior part inserts on the body of the hyoid bone, and its more
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anterior part inserts with the opposite mylohyoid into the midline raphe between the hyoid bone and the mandible. The superior surface of the mylohyoid is in
relationship with the lingual and hypoglossal nerves.
Sehirli and Çavdar21 reported a case of a left accessory mylohyoid muscle, located between the anterior belly of the digastric and the normal mylohyoid
muscles. The left accessory mylohyoid muscle extended from the mylohyoid line of the mandible to the lower part of the mylohyoid raphe and hyoid bone.
Hyoglossus Muscle. The thin and quadrilateral hyoglossus muscle arises from the greater horn and body of the hyoid bone. It ascends almost vertically into
the side of the tongue between the styloglossus muscle laterally and the inferior longitudinal musculature of the tongue. The hypoglossal nerve and its venae
comitantes enter the floor of the mouth over the posterior edge of the mylohyoid, lateral to the hyoglossus. From its origin in the neck, the lingual artery
passes deep to the hyoglossus muscle. It enters the floor of the mouth between the hyoglossus muscle laterally and the genioglossus muscle medially.
The nerve to the mylohyoid, which also supplies the anterior belly of the digastric, arises from the inferior alveolar branch of the mandibular division of the
trigeminal nerve. The mylohyoid nerve lies on the inferior surface of the muscle, between it and the digastric. The submandibular space can be thought of as
the combination of the sublingual and submaxillary spaces.
Middle Constrictor Muscle. The middle constrictor originates from the angle between the lesser and greater horns of the hyoid bone and from the stylohyoid
ligament. Its insertion is the median raphe. The fibers travel backward, with the highest ascending and overlapping the superior constrictor, and the lowest
fibers traveling down under the inferior constrictor.
Styloglossus Muscle. The styloglossus muscle has two origins and two insertions. The origins are from the front area of the styloid process and from the
stylomandibular ligament. Insertions are into the side of the tongue and at its inferior area.
Submandibular Space and Ludwig's Angina. The sublingual and submaxillary spaces, above and below the mylohyoid muscle, respectively, are continuous at
the posterior border of the mylohyoid. These spaces can be involved in the diffuse inflammation (cellulitis) of Ludwig's angina, which often results from
infections of the lower molar teeth, most commonly with streptococcus hemolyticus as the infectious agent. As noted by Lindner,22 the entire submandibular
space is bounded tightly by the attachments of the cervical investing fascia to the mandible, the mucous membrane of the floor of the mouth, the
attachment of cervical fascia to the hyoid bone, the hyoid bone itself, and the fascial investment of the posterior belly of the digastric. Edema here, and the
swollen and displaced tongue can cause asphyxiation. Infection of the submandibular space can spread posteriorly along the styloglossus muscle into the
pharyngomaxillary space. From this region, the process can pass into the retropharyngeal space and then inferiorly into the superior mediastinum.
Remember, in Ludwig's angina (as urged by Lindner22):
Cellulitic areas should not be incised. Incisions invite additional foreign organisms into an area that frequently (and early) becomes gangrenous.
Cellulitis should be met with systemic treatment with specific antibiotic therapy, and with local treatment with massive hot compresses and hourly hot saline
gavages to the oral cavity. Intravenous therapy should be used to maintain fluid and electrolyte balances.
To avoid asphyxiation, maintenance of an adequate airway is of utmost importance. Tracheotomy is imperative if the breathing becomes shallow and rapid.
Surgical division of the fascia and mylohyoid is performed only for complications such as drainage of pus under tension, erosion of cervical vessels by the infectious
process, and internal jugular vein thrombosis.
Fourth Surgical Plane: The Basement of the Submandibular Triangle
The structures of the fourth surgical plane, or basement of the triangle, include the deep portion of the submandibular gland, the submandibular (Wharton's)
duct, the lingual nerve, the sublingual vein, the sublingual gland, the hypoglossal nerve (XII), and the submandibular ganglion (Fig. 1-19). The uncinate part
of the submandibular gland rounds the posterior border of the mylohyoid to lie in the connective tissue above it. Here, the submandibular duct arises and
passes through the floor of the mouth to end at the sublingual caruncle beside the frenulum of the tongue anteriorly.
Fig. 1-19.
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The fourth surgical plane of the submandibular triangle. The deep portion of the gland and duct are exposed. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr.
Surgical anatomy of the submandibular triangle. Am Surg 1979;45:590-596; with permission.)
The submandibular duct lies below the lingual nerve (except where the nerve passes under it) and above the hypoglossal nerve.
Lymphatic Drainage
The submandibular lymph nodes receive afferent channels from the submental nodes, the oral cavity, and the anterior parts of the face. Efferent channels
drain primarily into the jugulodigastric, jugulocarotid, and juguloomohyoid nodes of the chain accompanying the internal jugular vein (deep cervical chain). A
few channels pass by way of the subparotid nodes to the spinal accessory chain.
The contents of the submandibular triangle are cleared out during radical neck dissection by removing the submandibular (submaxillary) gland and its envelope
and lymph nodes within, and by removing its capsule and all surrounding tissue without.
SUBMENTAL TRIANGLE
Boundaries
The boundaries of this triangle are:
Lateral: anterior belly of the digastric muscle
Inferior: hyoid bone
Medial: midline
Floor: mylohyoid muscle
Roof: skin and superficial fascia
Contents
The submental triangle contains lymph nodes. The contents of this triangle should be sacrificed in radical neck dissection.23
Lymphatic Drainage
The lymph nodes of the submental triangle receive lymph from the skin of the chin, the lower lip, the floor of the mouth, and the tip of the tongue. They send
lymph to the submandibular and jugular chains of nodes.
CAROTID TRIANGLE
Boundaries
The boundaries are:
Posterior: sternocleidomastoid muscle
Anterior: anterior (superior) belly of the omohyoid muscle
Superior: posterior belly of the digastric muscle
Floor: hyoglossus muscle, inferior constrictor of the pharynx, thyrohyoid muscle, middle constrictor of the pharynx, longus capitus muscle
Roof: investing layer of deep cervical fascia
Contents
The carotid triangle contains:
bifurcation of the carotid artery
internal carotid artery (no branches in the neck)
branches of the external carotid artery
– superior thyroid artery (rare)
– posterior auricular artery
– superficial temporal artery
– internal maxillary artery
– occipital artery
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– ascending pharyngeal artery
– sternocleidomastoid artery
– lingual artery (occasional)
– external maxillary artery (occasional)
– facial artery (occasional)
tributaries of the internal jugular vein
– superior thyroid vein
– pharyngeal vein
vagus nerve
spinal accessory nerve
hypoglossal nerve
ansa hypoglossi
cervical sympathetic trunks (partial)
Protection of nerves and vessels, and removal of the lymphatic tissue is essential.
The posterior belly of the digastric muscle —which is between the submandibular and carotid triangles— is a reliable landmark in a dangerous area. Deep to
the posterior belly, the following anatomic entities will be found:
internal and external carotid arteries
internal jugular vein
glossopharyngeal nerve (9th cranial nerve)
spinal accessory nerve (11th cranial nerve)
hypoglossal nerve (12th cranial nerve)
sympathetic trunk
Lymphatic Drainage
Lymph is received by jugulodigastric, jugulocarotid, and juguloomohyoid nodes, and by nodes along the internal jugular vein from the submandibular and
submental nodes, the deep parotid nodes, and the posterior deep cervical nodes. Lymph passes to the supraclavicular nodes.
MUSCULAR TRIANGLE
Boundaries
The boundaries are:
Superior lateral: anterior belly of the omohyoid muscle
Inferior lateral: sternocleidomastoid muscle
Medial: midline of the neck
Floor: prevertebral fascia and prevertebral muscles; sternohyoid and sternothyroid muscles
Roof: investing layer of the deep fascia; strap, sternohyoid, and cricothyroid muscles
Contents
The muscular triangle contains the thyroid and parathyroid glands, trachea, esophagus, and sympathetic nerve trunk. According to Beahrs,23 this triangle is
the least important.
Remember that occasionally the strap muscles must be cut to facilitate thyroid surgery. They should be cut across the upper third of their length to avoid
sacrificing their nerve supply.
Read an Editorial Comment
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Lymphatic Drainage
Lymphatic drainage of the muscular triangle will be discussed with the thyroid gland.
Posterior Cervical Triangle
The posterior cervical triangle is sometimes considered to be two triangles —the occipital and the subclavian— which are divided by the posterior (inferior)
belly of the omohyoid muscle (Fig. 1-20). We will treat it as one entity.
Fig. 1-20.
The posterior triangle of the neck. The triangle may be divided into two smaller triangles by the omohyoid muscle. (Modified from Skandalakis JE, Gray SW, Rowe JS
Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
BOUNDARIES
The boundaries are:
Anterior: sternocleidomastoid muscle
Posterior: anterior border of the trapezius muscle (Fig. 1-21)
Inferior: clavicle
Roof: superficial investing layer of the deep cervical fascia
Floor: prevertebral fascia and muscles, splenius capitus muscle, levator scapulae muscle, and three scalene muscles
Fig. 1-21.
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The floor of the posterior triangle.
CONTENTS
Between the investing fascia and the prevertebral fascia are the accessory nerve (XI) and a portion of the external jugular vein. Variably deep within the
triangle are the subclavian artery, subclavian vein, cervical nerves, brachial plexus, phrenic nerve, accessory phrenic nerve, spinal accessory nerve, and
lymph nodes.
LYMPHATIC DRAINAGE
Superficial occipital lymph nodes receive lymph from the occipital region of the scalp and the back of the neck. Efferent vessels pass to a deep occipital
lymph node (or occasionally to more than one node) which drains into deep cervical nodes along the spinal accessory nerve.
SURGICAL NOTES
The following are surgical points to remember for the upper or occipital part of the posterior triangle:
Clear the lymph nodes around the spinal accessory nerve very carefully.
Sacrifice the nerve if it is absolutely necessary.
Surgical points for the lower or subclavian part of the posterior triangle:
Be careful with the triangle's contents: the subclavian vein, portions of the transverse cervical vessels, and lymph nodes.
Surgical Applications of the Cervical Triangles
ANTERIOR TRIANGLE
In the past, inflammatory processes in the neck, such as Ludwig's angina, presented with severe mortality and morbidity. Although these inflammatory processes
still occur, they are far less common, with lower mortality, because effective antibiotics arrest and cure the inflammation.
Do not confuse the carotid sinus and the carotid body. Anatomically, the carotid sinus is a dilated area that is usually located at the beginning of the internal carotid
artery. There, the media is thin and poor in muscle. But the adventitia is thick; it is rich with elastic tissue, receptors, and sensory nerve fibers from the
glossopharyngeal nerve.
The carotid sinus (Fig. 1-22) acts as a baroreceptor, responding reflexively to changes in arterial pressure. Elevation of pressure or compression of the
carotid sinus can result in slowing of the heart rate, a sudden fall in arterial pressure, cerebral ischemia, and ipsilateral and secondary syncope.
Fig. 1-22.
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Diagram of the carotid sinus, carotid body, and their innervation. What part the carotid branch of the vagus plays in this innervation is not known. Note that the
carotid body lies not so much in, as medial to, the carotid bifurcation.
The carotid body (Fig. 1-22) is a tiny bilateral lobular anatomic entity 2 to 7 mm in size. It is located at the carotid bifurcation or on the posterior medial side
of the common carotid artery.24 It may be partially embedded in the carotid adventitia from which it developed embryologically. It is composed of a fibrous
capsule with septae which divide it into lobules composed of epithelioid glomus cells, supporting cells, and sinusoids. Tumors of the carotid body may develop
and present serious surgical problems, particularly with regard to hemorrhage during surgery.
The carotid body is a chemoreceptor which is sensitive to low levels of oxygen, high levels of carbon dioxide, or hydrogen ion concentrations. It responds to
these by reflexively increasing respiratory ventilation via its connections with the brainstem. Its nerve supply is derived principally from the glossopharyngeal
nerve, although it also seems to receive fibers from the vagus.
POSTERIOR TRIANGLE
The subclavian artery can be compressed against the first rib by pressure of the thumb placed in the supraclavicular fossa when the hand is grasping the neck.
One of the most common fractures is that of the clavicle, perhaps due in part to the fact that the middle one-third of the clavicle is not protected by muscular
attachments. The subclavius muscle does not have the power to protect the clavicle.
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The accessory nerve (XI) divides the posterior triangle into two nearly equal parts. Borrowing from the terminology of Grant and Basmajian,25 we refer to the upper
area as "carefree," and the lower area as "careful." The position of the accessory nerve in the posterior triangle can be ascertained as follows. First, place a point on
the anterior border of the trapezius one third of the distance between the acromion process and the back of the skull. Second, place a point on the posterior border
of the sternocleidomastoid, two-thirds of the distance from the clavicle to the mastoid process. A line drawn between the two points will lie over the course of the
accessory nerve, deep to the investing fascia. Erb's point, where the external jugular crosses the posterior border of the SCM, emphasizes the exit of the greater
auricular nerve along with cranial nerve XI.
We quote from Kierner et al.26 on the anatomy of the spinal accessory nerve (SAN) and the trapezius branches of the cervical plexus:
(1) The SAN can be found medial as well as lateral to the internal jugular vein, depending how far cranial in the neck it is identified. The crossing
between these 2 important structures can happen only dorsally (44%) or ventrally (56%) to the internal jugular vein...
(2) When the SAN passes through the sternocleidomastoid muscle, it takes an S-shaped, 3-dimensional course instead of running straight through the
muscle...If the nerve were followed through the muscle...the communicating branch(es) with the cervical plexus would obviously be cut.
(3) The cervical plexus branches passing to the trapezius muscle are always subfascial because another relationship to the fasciae of the neck whether superficial or deep - is anatomically impossible.
(4) The SAN can easily be mixed up with the minor occipital nerve because the latter sometimes takes a similar course, turning upward just slightly
medial to the anterior border of the trapezius muscle...Therefore, the supposed SAN must be followed right to the anterior border of the trapezius
muscle to be sure that it keeps its craniocaudal direction. Furthermore, we found that measuring at the posterior border of the sternocleidomastoid
muscle from the clavicle provides the most reliable results and that the nerve can always be identified. The other landmarks cited in the literature,
such as the great auricular nerve or the sternocleidomastoid muscle itself, show much more variability.
In a few preparations, cutaneous branches of the posterior spinal nerves passed through the tendon plane between the spinous processes of the
vertebral column and the trapezius muscle to reach the skin. However, in contradiction to some former works, they were never found to branch within
the muscle, which would have indicated additional innervation.
The following are descriptions of the anatomic entities (from above downward) within the "careful" areas, as well as some indications about their potential for injury.
– The spinal accessory nerve is closely related to the deep posterior cervical nodes. If an abscess is present in this area, make an incision just through the skin. Use
a hemostat to penetrate and drain the abscess. This method avoids injury to the nerve with resultant wasting of the trapezius and drooping of the shoulder.
– The brachial plexus can be injured in the lower part of the triangle by such diverse means as stab wounds, bullets, excessive abnormal traction at childbirth, falls
upon the shoulder, or other sources of blunt trauma.
– The subclavian artery and the brachial plexus can be compressed as they cross the first rib posterior to the anterior scalene muscle.
– The phrenic nerve passes inferiorly on the ventral surface of the anterior scalene muscle beneath the covering of the prevertebral fascia. Because this fascia is
drawn distally as the axillary sheath upon the brachial plexus and axillary artery, anesthetics injected into the sheath can affect the phrenic nerve, resulting in a
hemiparalysis of the diaphragm.
The topographic pathway and relations of the phrenic nerve with other anatomic entities in the neck:
1. Posterior to the inferior belly of the omohyoid muscle, very close to its intermediate tendon
2. Posterior to the internal jugular vein, transverse cervical, and suprascapular arteries
3. Posterior to the thoracic duct on the left neck
4. Anterior to the subclavian artery
5. Posterior to the subclavian vein
We quote from Kline et al.27:
The surgeon can feel the characteristic rounded anterior border of the scalenus anticus as he or she palpates through the fat and lymphoid tissue.
This is an important clue, as the novice tends to operate too far laterally and superiorly, thereby missing the brachial plexus altogether. The surgeon
can clear down to the anterior border of the scalenus anticus with dispatch, knowing that the phrenic nerve is deep to the prevertebral fascia at this
point. Once the phrenic nerve has been dissected free and guarded, the scalenus anticus can be divided after the surgeon has seen that the
subclavian artery is free from its posterior surface.
NOTE: At that point, the phrenic nerve enters the thoracic cavity, anterior to the internal thoracic artery and to the pulmonary hilum, between the
mediastinal pleura and the pericardium. Here the pericardiophrenic vessels are fellow travelers of the phrenic nerve.
The cervical pleura and the apical parts of the lungs extend upward above the clavicle into the root of the neck. Scalene lymph node biopsy can produce iatrogenic
pneumothorax or injury to the apex of the lung, as well as injury to the highest part of the left thoracic duct.
The external jugular vein passes downward from the area of the angle of the mandible to the middle of the clavicle. Just above the clavicle, the vein pierces the
investing fascia and drains into the subclavian vein. In this area, a penetrating neck wound with division of the vein can allow air to be sucked into the vein because
the deep fascia is fixed firmly to the venous wall, thereby keeping the lumen of the vein open. During inspiration a fatal air embolism may take place.
Remember, there are three topographic features in the vicinity of the supraclavicular triangle region of the "careful" part of the posterior triangle. The interscalene
groove and the supraclavicular fossa are present within the triangle; the infraclavicular fossa is located just under the middle one-third of the clavicle, outside of the
posterior triangle (Figs. 1-23, 1-24).
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Fig. 1-23.
The supraclavicular fossa, the infraclavicular fossa, and the jugular fossa.
Fig. 1-24.
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Compression of the subclavian artery and brachial plexus. A, muscle is relaxed; B, contraction of the anterior scalene muscle in the presence of a cervical rib can
produce compression of the subclavian artery and brachial plexus; C, scalenotomy alone may relieve this compression by allowing the vessel and nerves to drop
forward.
– Interscalene Groove: If the head is turned strongly to the opposite side, a triangle is formed by the clavicle inferiorly, the sternocleidomastoid muscle medially, and
the anterior border of the trapezius muscle laterally. The anterior and middle scalenes lie in the floor of this triangle. In different individuals, the groove between them
can be palpated with varying ease.
The position of the cricoid cartilage can be used to approximate the level of the 6th cervical vertebra. Likewise, Chassaignac's tubercle of the transverse process of
C6 can be palpated just behind the posterior border of the sternocleidomastoid. A point located in such fashion in the middle of the triangle approximates the site of
the passage of the subclavian artery and the emerging of the brachial plexus from between the anterior and middle scalenes. The second part of the subclavian
artery lies behind the anterior scalene muscle. A finger passed downward palpating in the interscalene groove will usually feel the pulse of the subclavian artery
without difficulty.28
– The Supraclavicular Fossa: The supraclavicular fossa is formed by the lateral (posterior) border of the sternocleidomastoid muscle, the anterior border of the
trapezius, and the proximal one-half or one-third of the clavicle. This is the pressure point of the subclavian artery, which may be palpated between the finger and
the first rib.
– The Infraclavicular Fossa: The infraclavicular fossa is the soft, palpable hollow located inferior to the middle of the clavicle. It is bounded by the pectoralis major,
deltoid, and clavicle. The axillary vein appears deep to the skin, superficial fascia, and clavipectoral fascia. The axillary artery, bounded by elements of the brachial
plexus, is located deep to the axillary vein. The apical and infraclavicular lymph nodes also are found in this fossa.
The anterior scalene muscle arises from the ventral tubercles of the transverse processes of the 4th through the 6th cervical vertebrae. It descends almost vertically
to insert on the scalene tubercle of the first rib, anterior to the groove for the subclavian artery. The middle scalene muscle, the largest of the three scalenes, arises
from the posterior tubercles of the transverse processes of vertebrae C2-C7. It inserts on the first rib between its tubercle and the subclavian artery groove. The
posterior scalene arises from the posterior tubercles of vertebrae C4-C6. It inserts upon the second rib.
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posterior scalene arises from the posterior tubercles of vertebrae C4-C6. It inserts upon the second rib.
Harry et al.29 reported that the commonly described anatomic relationship of the brachial plexus located between the anterior scalene and middle scalene
muscles was found only in 60 percent of cases. The same authors observed the following variations:
– The scalenus minimus muscle was present in 46 percent of instances (Fig. 1-25)
– In 15 percent of cases the anterior scalene muscle was penetrated by fused C5-C6 roots
Fig. 1-25.
Variations seen in relations between scalene muscles and the brachial plexus. A, subclavian artery piercing the anterior scalene muscle belly; B, roots of C5 & C6
piercing the anterior scalene muscle belly. (Modified from Harry WG, Bennett JDC, Guha SC. Scalene muscles and the brachial plexus: anatomical variations and their
clinical significance. Clin Anat 1997;10:250-252; with permission.)
The subclavian vein crosses the first rib ventral to the anterior scalene, where it is closely associated with, and often compressed by, the subclavius muscle.
Frequently, individuals thus affected have spontaneous or effort-related upper extremity axillary and subclavian venous thrombosis (Paget-von Schroetter
syndrome), unrelated to intercurrent illness or iatrogenic manipulation. Patients with this problem can be treated with a combination of thrombolytic agents
and anticoagulation, resection of the first rib, and balloon angioplasty.30
Thoracic outlet syndrome: The subclavian artery, in company with the brachial plexus and with contributions from cervical nerves C5-C8 and the 1st thoracic nerve,
passes between the anterior and middle scalene muscles. Here the artery and nerves cross the first rib, and can be subject to compression.
Thoracic outlet syndrome actually refers to compression at the upper opening (inlet, superior aperture). Perhaps the use of the word "outlet" is incorrect,
since the lower opening of the thorax is the true "outlet."
The topographic relations of the thoracic inlet:
Posterior: First thoracic vertebral body
Anterior: Superior border of the manubrium of the sternum
Lateral: First rib
We quote from Obuchowski and Ortiz31 on magnetic resonance (MR) imaging of the thoracic inlet:
The borders of the thoracic inlet define an oblique plane that angles downward from the spine anteriorly to the first ribs. It is therefore best to
consider the thoracic inlet as a region or "zone" which extends a short distance above and below this plane to include the lower portion of the
infrahyoid neck and the upper portion of the superior mediastinum. MR's multiplanar imaging capacity allows the thoracic inlet to be subdivided into four
distinct zones: visceral, neurovascular, pulmonary, and spinal.
Post-stenotic dilatation of the subclavian artery can be associated with the development of thrombi. These thrombi, discharged distally into the artery, can
produce confusing symptoms similar to carpal tunnel entrapment of the median nerve. Sanders and Pearce32 observed that 86% of patients suffering from
thoracic outlet syndrome had a history of some form of cervical trauma, especially whiplash injuries. In such individuals, scalenectomy is preferable to
resection of the first rib.
Accessory scalene musculature, fascial bands, or an atypical 7th cervical rib can, variably, compress the artery, the nerves, or both. This compression
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Accessory scalene musculature, fascial bands, or an atypical 7th cervical rib can, variably, compress the artery, the nerves, or both. This compression
results in scalenus anticus (anterior scalene) syndrome, with pain, paresthesia or weakened pulses. During development, the 7th cervical rib forms, and then
normally regresses to its transverse process. Variations in its fate vary from a fully formed rib to rudimentary forms associated with a fibrocartilaginous band.
In a study of 390 transaxillary resections of the first rib for arterial, venous, or brachial plexus compression at the thoracic outlet, Makhoul and Machleder33
found that 66% of the 175 patients had single or multiple abnormalities representing developmental variations: 86 scalene and 39 subclavius muscles were
atypical in form or attachments; 20 scalene muscles were supernumerary; and 17 ribs exhibited abnormalities (7th cervical or atypical 1st thoracic).
In another study of patients suffering from thoracic outlet syndrome, Machleder et al.34 showed that there were demonstrable morphologic transformations of
anterior scalene muscle fibers that reflect metabolic and enzymatic changes characteristic of various adaptive and pathologic processes. In such changes,
attributable to traumatic stress and stretch injury, muscle fibers change from a fast-twitch type 2 fiber to a hypertrophied slow-twitch type 1 fiber. Such
changes occur predominantly in young individuals in response to exercise.
The presence of a cervical rib (found in about 1% of cases) often was shown to be indicative of a variation in the scalene musculature or in the brachial
plexus where the first thoracic nerve had little input, replaced by a major contribution from C4. When the C7 rib was incomplete, the regressed part of the rib
was often replaced by a fibrous band. About 67% of cervical ribs are bilateral. In Makhoul and Machleder's33 study of patients suffering from Paget-von
Schroetter syndrome, 55% had hypertrophy of the tendon of the subclavius muscle as well as enlargement of the insertion tubercle.
Paget-von Schroetter syndrome is frequently associated with thrombosis of the axillary-subclavian vein from exertion, leading to the phrase "effort vein
thrombosis." The condition develops as an abrupt swelling of the upper extremity. According to Flye,35 even with early medical treatment complete resolution
occurs in only 15% to 30% of patients.
Fasciae of the Neck
The following classification of the rather complicated fascial planes of the neck follows the work of several investigators:
Superficial fascia
Deep fascia
– Investing layer (superficial layer)
– Middle, or pretracheal, layer (surrounding the larynx, trachea, and pharynx)
– Prevertebral layer (posterior or deep layer)
Superficial Fascia
The superficial fascia of the neck lies beneath the skin. It is composed of loose connective tissue, fat, the platysma muscle, cutaneous branches of the
cervical plexus, the cervicofacial division of the facial nerve and small cutaneous blood vessels (Fig. 1-26). The surgeon should remember that the cutaneous
nerves of the neck and the anterior and external jugular veins are between the platysma and the deep cervical fascia. If the veins are to be cut, they must
first be ligated. Because of their attachment to the platysma above and the fascia below, they do not retract; bleeding from them can be serious, and the
surgeon must guard against the possibility of production of an air embolism. For all practical purposes, there is no space between this layer and the deep
fascia.
Fig. 1-26.
The superficial fascia of the neck lies between the skin and the investing layer of the deep cervical fascia. CT, connective tissue. (Modified from Skandalakis JE, Gray
SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Deep Fascia
INVESTING LAYER
The superficial (investing) layer of the deep cervical fascia (Figs. 1-26 and 1-27) attaches above to the occipital and temporal bones and the mandible,
posteriorly to the spines and supraspinous ligaments of the cervical vertebrae, and below to the clavicle, scapula, and manubrium of the sternum. It envelops
two muscles —the trapezius and sternocleidomastoid— and two glands —the parotid and submandibular. It forms two spaces —the supraclavicular and
suprasternal; and forms the roof of the anterior and posterior cervical triangles.
Fig. 1-27.
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Fascial layers and spaces above the hyoid bone, in a sagittal section. Note that the "danger space" and the retropharyngeal space show no interruption, but are
continuous with the danger space and the retrovisceral space, respectively, below the level of the hyoid bone. Note also that under normal circumstances, these are
"potential," rather than "actual" spaces. (Based on Hollinshead WH. Anatomy for Surgeons, Vol. 1, 2nd Ed. New York: Harper & Row, 1968.)
PRETRACHEAL LAYER
The middle (pretracheal) layer of the deep fascia (Fig. 1-28) is sometimes described as investing the strap muscles anteriorly, merging with the superficial
investing layer. Conversely, it is also said to be a lamina that passes deep to the strap muscles, uniting with the superficial investing layer lateral to them.36
In keeping with the former view, it is said that a posterior layer of the pretracheal fascia envelops the thyroid gland, forming the false capsule of the gland
(Fig. 1-29). This layer is fixed to the thyroid and cricoid cartilages above. The attachment to the cartilages may be thickened to form the suspensory
ligament of the thyroid gland (ligament of Berry).
Fig. 1-28.
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Fascial layers of the neck. A, Cross section. D, "danger space" within the prevertebral fascia; RV, retrovisceral or retropharyngeal space between the prevertebral
fascia and the pretracheal (visceral) fascial layers. B, Chief fascial layers of the neck below the hyoid bone, in longitudinal section. (A, From Colborn GL, Skandalakis
JE. Clinical Gross Anatomy: A Guide for Dissection, Study, and Review. Pearl River NY: Parthenon, 1993; B, modified from Hollinshead, Anatomy for Surgeons, Vol 1:
The Head and Neck, New York: Harper & Row, 1968; with permission.)
Fig. 1-29.
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The anchor of the thyroid gland: the ligament of Berry.
Posteriorly, the middle cervical fascia becomes ill-defined, permitting an enlarging thyroid gland to extend posteriorly. This posterior, or deep, portion of the
pretracheal fascia can be thought of as the visceral portion of this fascial layer. It is continuous posteriorly with the buccopharyngeal and esophageal
fasciae, as noted some time ago by Grodinsky and Holyoke.37 It is because of this continuity that some prefer the term "visceral layer" to "pretracheal layer,"
as the more appropriate name for the middle layer of deep cervical fascia.
Anteriorly, the middle layer attaches above to the hyoid bone and below to the fibrous pericardium. Laterally, it contributes to the carotid sheath. Posteriorly,
this fascial layer continues as buccopharyngeal fascia to the base of the skull; it terminates inferiorly at about the level of the bifurcation of the trachea by
blending with the alar part of the prevertebral fascia.
PREVERTEBRAL LAYER
The prevertebral (posterior) layer (Fig. 1-27) lies in front of the prevertebral muscles. It originates from the spinous processes and the ligamentum nuchae
posteriorly, and covers the cervical spine muscles, including the scalene muscles and vertebral column anteriorly. At its attachment to the transverse
processes of the cervical vertebrae, the prevertebral fascia divides to form a space in front of the vertebral bodies, the anterior layer being the alar fascia,
the posterior layer retaining the designation of prevertebral fascia.
CAROTID SHEATH
Three fasciae —investing, pretracheal, and prevertebral— compose a fascial tube, the carotid sheath (Fig. 1-28, Fig. 1-30), beneath the sternocleidomastoid
muscle. Within this tube lie the common carotid artery, internal jugular vein, vagus nerve, and deep cervical lymph nodes. In the upper part of the neck, the
connective tissue of the sheath blends with the fascial investments of the stylohyoid muscle and the posterior belly of the digastric. Above this, the sheath
becomes more adherent to the adventitial coverings of the carotid vessels and internal jugular vein.
Fig. 1-30.
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Two views of the visceral compartment of the neck.
Inferiorly, the carotid sheath is adherent to the posterior aspect of the sternum and clavicle and is lateral to the origins of the sternocleidomastoid and strap
muscles. Posteriorly, it is fused with the first rib and Sibson's fascia. In the root of the neck, the visceral fascia passes on to the alar fascia of the carotid
sheath, continuing into the thorax to the fibrous pericardium of the heart and great vessels. As the sheath passes into the thorax, the connective tissue of
the sheath separately encloses each structure within as they diverge from one another.
Behind the carotid sheath, the prevertebral fascia covers the scalene muscles and phrenic nerve, and provides origin for the axillary sheath. The potential
danger space of Grodinsky and Holyoke37 (Figs. 1-27 and 1-28) lies between the alar component and the deeper, muscular part of the prevertebral fascia.
This space provides a plane for the spread of fluids or pathologic processes from the base of the skull to the thoracic diaphragm.
BUCCOPHARYNGEAL FASCIA
The buccopharyngeal fascia (Fig. 1-27) is continuous below with the visceral fascial covering of the esophagus. Superiorly, it covers the posterior and lateral
surfaces of the pharynx and continues forward over the external surface of the buccinator muscle of the cheek. It is joined rather loosely by delicate areolar
tissue to the alar layer of the prevertebral fascia. The interval between the two fascial layers is the retropharyngeal space (Fig. 1-27) which extends
superiorly to the skull base and terminates inferiorly in the upper part of the thorax. This space can be infected by descending infections, by direct
perforations of the esophagus, or by infections of the deep cervical lymph nodes which lie adjacent to it.36
AXILLARY FASCIA
The axillary fascia takes its origin from the prevertebral fascia. It is considered in the chapter on the breast under the heading "Topographic Anatomy and
Relations: Deep Fascia."
Spaces of the Neck
There are many spaces in the neck that are defined by the fasciae (Figs. 1-27, 1-28). Because this book is for the general surgeon, only those spaces that
need special emphasis will be described. Some others, such as the parotid and submaxillary spaces, will be discussed with the organs they are related to. The
authoritative works on the cervical spaces are those of Grodinsky and Holyoke37 and Coller and Yglesias.38
Spaces above the Hyoid Bone
Intrafascial spaces are formed by splitting of the several fascial layers of the neck. The spaces are those related to the body of the mandible, and the submaxillary,
parotid, and masticator spaces.
Peripharyngeal spaces include the retropharyngeal, lateral pharyngeal, and submandibular spaces. Buser and Bart39 studied the normal anatomy of the
retropharyngeal space (Fig. 1-27): this involves the posterior neck in toto from the base of the skull to the level of T1, T2 in the upper mediastinum in front of the
prevertebral fascia and behind the buccopharyngeal or visceral fascia. The lateral pharyngeal space (Fig. 1-31) is a lateral extension of the retropharyngeal space
around the pharynx. The submandibular space (Fig. 1-27) is related to the anterior elements of the several peripharyngeal spaces; it is highly complex.
Fig. 1-31.
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Part of a diagrammatic semifrontal section, slanted somewhat anteriorly from behind the ramus of the mandible, to show the relations of the superficial layer of
fascia to the parotid gland.
Spaces below the Hyoid Bone
The following are the spaces below the hyoid bone (Fig. 1-28A&B, Fig. 1-30):
Visceral compartment (of Stiles)
Carotid sheath (see "Carotid Sheath" under "Deep Fascia" in this chapter)
Space between the prevertebral and alar fasciae, the danger space of Grodinsky and Holyoke 37 (see "Prevertebral Layer" under "Deep Fascia" in this chapter)
The suprasternal space, or space of Burns.
VISCERAL COMPARTMENT
The boundaries of the visceral compartment of the neck (the space of Stiles) (Fig. 1-30) are as follows:
Anterior: Pretracheal fascia
Posterior: Prevertebral fascia
Lateral: Carotid sheath
Superior: Hyoid bone and thyroid cartilage
Posteroinferior: Posterior mediastinum
Anteroinferior: Bifurcation of the trachea, at the level of the 5th thoracic vertebra
The contents of the visceral compartment are the larynx, trachea, thyroid, parathyroid glands, and part of the esophagus.
The lower part of the visceral compartment is subdivided into an anterior pretracheal space and a posterior retrovisceral (retroesophageal) space. These
spaces are separated by lateral attachments of the esophagus to the prevertebral fascia. The spaces are confluent above.37
These spaces of the visceral compartment, together with the carotid sheath, are the chief pathways of infection. Pearse40 stated that in neck infections
that spread to the mediastinum, 71 percent spread through the retrovisceral space, 21 percent through the carotid sheath, and 8 percent through the
pretracheal space.
SUPRASTERNAL SPACE
The suprasternal space (space of Burns) is formed by a splitting of the superficial investing layer of the deep cervical fascia. The anterior lamina is attached
to the anterior surface of the sternum. The posterior lamina is attached to the posterior aspect of the manubrium. Within this space are the lower ends of
the anterior jugular veins and an interconnecting venous arch. Some lymphatic tissue and fatty tissue are often present here as well.
Surgical Applications of the Cervical Fasciae and Spaces
Two abscesses are related to the prevertebral fascia. One is anterior to it, between the fascia and the posterior lateral wall of the pharynx. This is an acute
retropharyngeal abscess (Fig. 1-32). The other is located behind the prevertebral fascia, is secondary to tuberculosis or other osteomyelitis of a cervical vertebra, and
is chronic.
The pretracheal compartment of Stiles is limited above by the hyoid bone, and enters below into the anterior mediastinum. It can be approached surgically by any
kind of incision medial to the sternocleidomastoid and carotid sheath.
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Collections of fluid deep to the prevertebral fascia can track distally down the upper extremity to the level of the elbow by transit within the axillary sheath.
Fig. 1-32.
Chronic and acute retropharyngeal abscesses.
Vascular Supply of the Neck
Despite the fact that we will present the vascular supply of each organ in the neck, at the present time the overall vascular supply will be presented in
summary fashion. The topographic anatomy presented here is based on Montgomery.41
Arteries
COMMON CAROTID ARTERIES
The neck is supplied by the common carotid arteries. The right common carotid arises from the bifurcation of the brachiocephalic trunk and the left common
carotid from the aortic arch (Figs. 1-33, 1-34).
Fig. 1-33.
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Diagrammatic representation of both common carotid arteries (posterior view). (Modified from Montgomery RL. Head and Neck Anatomy: With Clinical Correlations.
New York: McGraw-Hill, 1981; with permission.)
Fig. 1-34.
Common carotid artery and internal and external carotid arteries. (Modified from Montgomery RL. Head and Neck Anatomy: With Clinical Correlations. New York:
McGraw-Hill, 1981; with permission.)
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General Topography
The common carotid artery can be divided arbitrarily into three parts: inferior, middle and superior. The inferior part is behind the sternoclavicular joint on the
right, and is intrathoracic on the left. The middle section is located in the neck. The superior part bifurcates to the internal and external carotid arteries.
In most cases the common carotid artery has no branches in the neck. However, we have often seen the superior thyroid artery arise from the superior part
of the common carotid artery just below and close to the bifurcation, which is the most common location of the carotid body (Fig. 1-35).
Fig. 1-35.
Schema of the embryology, anatomy, and physiology of the carotid body and carotid sinus, and the pathology of the carotid body. (Modified from Singhabhandhu B,
Gray SW, Bryant MF, Skandalakis JE. Carotid body tumors. Am Surg 1973;39:501-508; with permission.)
Remember
The common carotid arteries are enveloped within the carotid sheath together with the internal jugular vein and the vagus nerve.
At its cranial end, the internal jugular vein is ventrolateral to the common carotid artery. More inferiorly, it becomes dorsolateral to the artery.
The vagus nerve is between these two vessels in a posteromedial position.
The vertebral artery normally arises from the first part of the subclavian artery, thereafter passing into the transverse foramen of the 6th cervical vertebra. In about
4% of cases, the left vertebral artery arises directly from the aortic arch. In approximately 6% of cases, the vertebral artery may enter the 7th or 5th transverse
foramen; rarely it enters at even higher levels. The surgical significance of high entry is that in such cases the inferior thyroid artery may pass deep to the aberrant
vertebral artery. This results in a potential for fatal hemorrhage or injury to other structures if the artery is torn while attempting to mobilize the inferior thyroid
artery.
Johnson et al.42 reported that early recurrent stenosis of the carotid artery occurred less frequently after endarterectomy using polytetrafluoroethylene (PTFE)
patch angioplasty than with primary closure or in dacron patch angioplasty.
Relations
Topographically, the origin of the right common carotid is located behind the right sternoclavicular joint. The origin of the left common carotid is
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intrathoracic; as it enters the root of the neck, it passes posterior to the left sternoclavicular joint. At that level the two common carotid arteries are 2½ 3½ cm apart, separated by the trachea. From that point, both carotid arteries have a length of 8-12 cm, terminating at the level of the 4th cervical vertebra
and at the superior level of the thyroid cartilage. There they bifurcate to the external and internal carotid arteries. The larynx separates them from one
another at 5½ - 6½ cm. The surface anatomy of the common carotid can be outlined by a line drawn from the sternoclavicular joint to the neck of the
mandible posteriorly. In each triangle, the pathway of the common carotids is different.
In the region of the muscular triangle, a hypertrophic thyroid gland will cover the common carotid artery; the middle thyroid vein crosses anterior to the
artery. To explore the artery in this area, the platysma muscle and the superficial investing layer of the deep cervical fascia should be incised, the
sternocleidomastoid muscle should be retracted medially, and the infrahyoid muscles and their fasciae should also be incised.
At the carotid triangle the artery has anterior, posterior and medial relations of importance. Anteriorly, the platysma muscle and the superficial investing layer
of the deep cervical fascia cover the artery; there, above the omohyoid muscle, the carotid is crossed by the superior thyroid artery and vein and its
sternocleidomastoid branch.
The posterior relations are as follows:
Retropharyngeal space
Prevertebral fascia
Cervical sympathetic nerves and ganglia
Longus coli muscle
Longus capitis muscle
Anterior tubercles of the transverse processes of the 4th, 5th, 6th, and 7th cervical vertebrae
Vertebral artery and vein
Medial to the common carotid are the following anatomic entities:
Lower part of the pharynx
Thyroid cartilage
Cricoid cartilage
Lateral aspect of the thyroid lobe
Branches of the inferior thyroid artery
Recurrent laryngeal nerve
Esophagus
Trachea
At the right sternoclavicular joint, the common carotid is medial to the internal jugular vein. The left carotid is behind the internal jugular vein. The thoracic
duct is located dorsal to the artery on the left. The right recurrent laryngeal nerve crosses the dorsal side of the first part of the right common carotid
artery.
Variations of the great arteries of the carotid triangle were studied by Lucev et al.43 in an excellent paper that we recommend to the interested student.
Collateral Circulation
According to Montgomery,41 collateral circulation of the common carotid artery (Fig. 1-36) is carried on chiefly by:
Anastomosis of the internal carotid of one side with the internal carotid of the opposite side and with both vertebral arteries through the cerebral arterial circle
Anastomosis of the inferior thyroid with the superior thyroid
Anastomosis of the deep cervical branch of the costocervical trunk with the descending branch of the occipital
Anastomosis of the superior thyroid, lingual, facial, occipital, and temporal with corresponding arteries of the opposite side
Anastomosis of the ophthalmic with the angular
Fig. 1-36.
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Some of the collateral channels available after ligation of the common carotid artery. On the right side of the body are shown the chief communications between the
two sides; on the left, the chief longitudinal anastomoses.
INTERNAL CAROTID ARTERY
The internal carotid artery (Fig. 1-37) is located within the carotid triangle, under and deep to the stylohyoid muscle and the posterior belly of the digastric
muscle. The internal carotid does not give origin to any branches in the neck, since its supply is limited to intracranial structures. It is crossed laterally by the
hypoglossal nerve.
Fig. 1-37.
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Internal and external carotid arteries. (Modified from Montgomery RL. Head and Neck Anatomy: With Clinical Correlations. New York: Mc Graw-Hill, 1981; with
permission.)
An aberrant internal carotid artery was reported by Cole and May44 as a vascular abnormality of the middle ear. These authors were able to collect 45 cases.
Papon et al.45 discussed the existence of anastomoses between the internal carotid and vertebral arteries (or artery) in the neck. These findings suggest a
possible need for modifying surgical technique during endarterectomy. Meder et al.46 reported six cases of segmental agenesis of the internal carotid artery.
Carsten et al.47 recommended Doppler screening examinations to detect asymptomatic carotid stenoses.
EXTERNAL CAROTID ARTERY
General Topography
The external carotid artery begins at the bifurcation of the common carotid artery at C4. It continues upward to a point posterior to the neck of the mandible
(approximately 1.5 cm below the zygomatic arch) where it bifurcates to form the maxillary and superficial temporal arteries. The superior thyroid, lingual, and
facial arteries arise from the ventral aspect near the origin of the external carotid; the ascending pharyngeal, occipital and posterior auricular branches arise
from the dorsal side of the external carotid. The 8 variable branch arteries of the external carotid are: maxillary, superficial temporal, superior thyroid, lingual,
facial, ascending pharyngeal, occipital, and posterior auricular arteries.
Relations
The hypoglossal nerve passes lateral and anterior to the external carotid artery just above the level of the hyoid bone. The external carotid is located
superficially and somewhat anterior and medial to the internal carotid artery. Intervening between the internal and external carotid arteries are several
anatomic entities:
stylopharyngeus muscle
styloglossus muscle
styloid process
glossopharyngeal nerve
pharyngeal branches of the vagus nerve
The anatomy of the branches of the external carotid artery will be discussed with related organs.
SURGICAL APPLICATIONS OF ARTERIAL ANATOMY
Occasionally the external carotid artery may be absent on one or both sides.
The branches of the missing vessels arise from the external or common carotid on the other side.
The internal carotid may be absent rarely.
The common carotid may bifurcate high at the level of the hyoid bone, or lower at the level of the cricoid cartilage.48
Several nerves of the neck are related to the internal carotid artery. It is important to be aware of potential injury to cranial nerves XII and X, especially during
carotid surgery.
Ligation of the external carotid artery can be done with impunity if the internal carotid artery is not injured (Fig. 1-38). The ligation can be done above or below the
origin of the superior thyroid artery if necessary.
Despite abundant collateral circulation of the common carotid artery, unilateral ligation of the artery should never be done unless it is absolutely necessary,
according to Hollinshead 36 (see Fig. 1-36). Ligation of the common carotid artery has been said to reduce the blood flow of the internal carotid artery and, therefore,
the supply to the brain by approximately 50%.36 According to Roberts et al.,49 the external carotid artery also delivers blood to the internal carotid (by virtue of the
anastomoses of the two). But, even if there is no vascular disease, it is sufficient in only 50% of the cases. This occurs because flow tends to be from the internal
carotid to the external carotid (the opposite of that anticipated), thus diverting even more blood flow from the brain.
Ligation of the internal carotid artery should be absolutely avoided (Fig. 1-38). According to Dandy,50,51 there was a death rate of 4% following ligation of the
internal carotid for intracranial aneurysms. Pemberton and Livermore 52 reported a death rate of 15.7% in a study of internal carotid ligations in 51 cases for reasons
other than intracranial aneurysms. They also reported that 30% of patients who had tumors of the carotid body died as a result of ligation of the internal carotid.
Drake et al.53 reported 133 cases of aneurysm arising from the internal carotid artery. They used internal carotid occlusion in 131 cases and common carotid occlusion
in 2, and stated that Hunterian proximal arterial occlusion can be done with safety.
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Fig. 1-38.
Ligation guidelines.
Kuehne et al.54 found that the neurologic outcome after internal carotid artery injury is enhanced by an algorithm based on the liberal use of angiography, a
predefined surgical approach, and selective observation. These authors also do not advocate ligation of the internal carotid artery. The algorithm is as
follows:
1. Hemodynamically stable patients with suspected internal carotid artery (ICA) injuries undergo a diagnostic angiography.
2. Reconstruct surgically accessible injuries regardless of neurologic status, with two exceptions:
a. Neurologically intact patients with ICA occlusion are treated by anticoagulation and mild pharmacological hypertension.
b. Minimal nonocclusive injuries are managed nonoperatively and followed up by serial angiography or duplex ultrasonography.
3. Heparinization, shunting, and completion angiography are employed.
In the discussion section of the article by Kuehne et al.,54 the ability to repair the internal carotid artery was questioned because of the relative
inaccessibility of two-thirds of its length. The authors responded that they had been able to repair the majority of injuries using standard techniques.
The patient with injury of the internal carotid artery may develop hemorrhagic infarction in the reperfused ischemic brain,55 or cerebrovascular morbidity such as
cerebral edema and herniation.54
As reported by Okamoto,56 the only therapy offering any potential cure or palliation in advanced head and neck cancer with involvement of the carotid artery is
resection of the carotid artery.
Marien and Thompson57 report a case of an anomalous occipital artery originating from the cervical internal carotid artery and not from the posterior wall of
the external carotid artery.
Ballotta et al.58 stated that cranial and cervical nerve injury after carotid endarterectomy is a common major or minor complication.
Guterman et al.59 reported that carotid endarterectomy for revascularization of the cervical carotid bifurcation provides a good alternative to open surgery
for patients who are considered at risk for excessive morbidity and mortality.
Veins
INTERNAL JUGULAR VEIN
The internal jugular vein (Fig. 1-39) is the principal vein of the head and neck; it is the downward continuation of the sigmoid sinus. The vein exits the skull,
along with cervical nerves IX, X, and XI, through the jugular foramen. Until it reaches the level of the superior border of the thyroid cartilage, the internal
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along with cervical nerves IX, X, and XI, through the jugular foramen. Until it reaches the level of the superior border of the thyroid cartilage, the internal
jugular vein lies to the external side of the internal carotid artery. Later, it takes a position along the lateral side of the common carotid artery within the
carotid sheath. Finally, close to its termination, it is located anterior to the artery. It is located under the sternocleidomastoid muscle. The veins that empty
into the internal jugular vein will be described with the related organs.
Fig. 1-39.
Internal jugular vein. (Modified from Montgomery RL. Head and Neck Anatomy: With Clinical Correlations. New York: McGraw-Hill, 1981; with permission.)
EXTERNAL JUGULAR VEIN
The external jugular vein passes obliquely and superficial to the sternocleidomastoid muscle deep to the platysma. The external jugular vein begins near the
angle of the mandible, at the junction of the posterior division of the retromandibular vein with the posterior auricular vein.
Erb's point is where the external jugular crosses the posterior border of the sternocleidomastoid; here, the vein is very closely related to several of the
cervical cutaneous nerves. The great auricular nerve and the transverse cutaneous nerve are of particular importance because of their sensory supply to the
lower part of the ear and the lower part of the face in the region of the angle of the mandible. This is also the site of the exit of cranial nerve XI.
In its course, the external jugular vein communicates with the internal jugular and receives a number of tributaries in the neck, including transverse cervical
and suprascapular veins. It usually ends by piercing the superficial investing layer of deep fascia and joining the subclavian vein, although it can also
terminate in the internal jugular.
Remember
The external jugular vein may be ligated with impunity if the internal jugular vein is intact.
Lymphatic Structures of the Neck
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Lymphatic Structures of the Neck
NUMBER OF LYMPH NODES
There is a significant range in the number of lymph nodes believed to be in the neck. Bailey & Love's60 reported that there are about 800 lymph nodes in the
human body, 300 of which are in the neck. In contrast, Gray's Anatomy61 reported that the adult body contains only 400-450 lymph nodes, with 60-70 in
the region of the head and neck.
Carlson stated (personal communication between G.W. Carlson and J.E. Skandalakis, April 22, 1996), "There are many lymph nodes in the first echelon
drainage of the oral cavity and oropharynx that are never surgically removed so I feel that the total number of lymph nodes could be approximately 150 to
300."
Drinker and Yoffey62 wrote that all the lymphoid tissue in the human body (including the lymphocytes in bone marrow) probably corresponds to nearly 1% of
the total body weight. This may equal a mass half the weight of the liver.
LEVELS OF THE NODES
The anatomy and pathology of cervical and retropharyngeal lymph nodes has been evaluated by computed tomography by Mancuso et al.63,64 From a
surgical standpoint, however, the lymph nodes of the neck are divided into 5 groups, or levels. There is no widespread agreement on the nomenclature of
lymph nodes and their division into groups. We consider the system of Healey65 to be the best and the easiest to remember; the "chains" of nodes are shown
in Fig. 1-40. The groups composing these chains are listed in Table 1-2. Some of the nodes of the intermediate vertical chain are shown in Fig. 1-41.
Table 1-2. Lymph Nodes and the Lymphatic Drainage of the Head and Neck
Lymphatics
Location
From
To
Submental nodes
Submental triangle
Skin of chin, lip, floor of mouth, tip of tongue
Submandibular nodes or jugular chain
Submandibular nodes
Submandibular triangle
Submental nodes, oral cavity, face, except
forehead and part of lower lip
Intermediate jugular nodes, deep posterior
cervical nodes
Preauricular (parotid)
nodes
In front of tragus
Lateral surface of pinna, side of scalp
Deep cervical nodes
Postauricular (mastoid)
nodes
Mastoid process
Temporal scalp, medial surface of pinna,
external auditory meatus
Deep cervical nodes
Between mastoid process and external
occipital protuberance
Back of scalp
Deep cervical nodes
Subparotid nodes, jugular chain, occipital, and
mastoid area
Supraclavicular and deep cervical nodes
All other nodes of neck
Lymphatic trunks to left and right thoracic
ducts
Superior horizontal chain:
Occipital nodes
Vertical chain:
Posterior cervical (posterior
triangle) nodes
Superficial
Along exterior jugular vein
Deep
Along spinal accessory nerve
Intermediate (jugular)
nodes
Juguloparotid (subparotid) Angle of mandible, near parotid nodes
nodes
Jugulodigastric
(subdigastric) nodes
Junction of common facial and internal
jugular veins
Jugulocarotid (bifurcation) Bifurcation of common carotid artery
Palatine tonsils
Tongue, except tip
nodes
close to carotid body
Juguloomohyoid
(omohyoid) nodes
Crossing of omohyoid and internal
jugular vein
Tip of tongue
Parapharyngeal nodes
Lateral and posterior wall of pharynx
Deep face and esophagus
Intermediate nodes
Paralaryngeal nodes
Lateral wall of larynx
Larynx and thyroid gland
Deep cervical nodes
Paratracheal nodes
Lateral wall of trachea
Thyroid gland, trachea, esophagus
Deep cervical and mediastinal nodes
Cricothyroid ligament
Thyroid gland, pharynx
Deep cervical nodes
Anterior wall of trachea below isthmus
of thyroid gland
Thyroid gland, trachea, esophagus
Deep cervical and mediastinal nodes
Axilla, thorax, vertical chain
Jugular or subclavian trunks to right
lymphatic duct and thoracic duct
Anterior (visceral) nodes
Prelaryngeal (Delphian)
nodes
Pretracheal nodes
Inferior horizontal chain:
Supraclavicular and scalene Subclavian triangle
nodes
Source: Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.
Fig. 1-40.
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The lymph nodes of the neck from Healey's classification. SH, Superior horizontal chain. IH, Inferior horizontal chain. PV, Posterior vertical chain. IV, Intermediate
vertical chain. AV, Anterior vertical chain. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill,
1983; with permission.)
Fig. 1-41.
Some drainage to lymph nodes of the intermediate vertical (jugular) chain. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General
Surgery. New York: McGraw-Hill, 1983; with permission.)
Level I (Submental and Submandibular Nodes)
Level I consists of all lymph nodes within the submental and submandibular triangles, i.e., between the anterior midline and the anterior border of the
posterior belly of the digastric muscle.
Level II (Upper Jugular Chain)
This level includes all deep jugular lymph nodes in the upper one-third of the neck. Arbitrarily, that area is bounded by the upper one-third of the posterior
border of the sternocleidomastoid muscle and the medial border of the posterior belly of the digastric. The boundary extends above to the occipital area and
below to a line corresponding to the pathway of the great auricular nerve, where it crosses the upper part of the sternocleidomastoid obliquely. The
jugulodigastric (subdigastric) node also belongs to this level.
Level III (Midjugular Chain)
This is a near-triangle formed (below) by the anterior belly of the omohyoid muscle, laterally (posteriorly) by the posterior border of the middle one-third of
the sternocleidomastoid muscle, and medially by the hyoid bone.
Level IV (Lower Jugular Chain)
The boundaries of Level IV consist of the posterior or lateral border of the lower third of the sternocleidomastoid, superiorly of the omohyoid muscle, and
inferiorly of the clavicle. The juguloomohyoid and deep lower jugular lymph nodes are located within this space.
Level V (Posterior Cervical Triangle)
This is the posterior triangle of the neck, which includes the posterior cervical lymph nodes in toto (spinal accessory nodes, inferior horizontal chain, scalene
nodes).
Kraus et al.66 reported a small incidence of supraspinal lymph node metastasis in patients with squamous cell carcinoma of the oral cavity and oropharynx
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with negative lymph nodes.
SPECIAL LYMPH NODES
Virchow's node, also called the signal node, is located just above the middle third of the left clavicle. When sufficiently enlarged and firm enough to be palpable, it is
usually presumptive evidence of malignant neoplasm below the diaphragm.
The Delphian node is found just above the thyroid isthmus.
The neck also contains a number of subepithelial lymphoid structures, the tonsils.
Tonsils
The opening between the nasal and oral cavities and the pharynx is guarded by a group of lymphoid structures collectively referred to as the ring of Waldeyer
(Fig. 1-42).
Fig. 1-42.
The lymphoid structures of the tonsillar ring of Waldeyer surrounding the pharynx. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in
General Surgery. New York: McGraw-Hill, 1983; with permission.)
On the roof of the nasopharynx, at the superior aspect of the ring of Waldeyer, is the pharyngeal tonsil (adenoids). The lingual tonsils are at the inferior
aspect of the ring, on the sides of the base of the tongue. Laterally, the palatine tonsils guard the entrance to the pharynx. There may be a band of
superficial lymph nodules, the lateral band, between the pharyngeal and palatine tonsils. These tonsillar organs differ from lymph nodes in that they provide
origin to, but do not receive, lymphatic vessels; Fig. 1-42 shows the lymph nodes into which they drain.
MASSES IN THE NECK
The human neck is designed such that the swelling of a normal structure or the presence of an abnormal one is readily apparent. Neoplasms and infections
can affect any of the 60-70 lymph nodes or the more than a dozen fascial spaces in the neck. Persistent embryonic structures may occupy spaces no longer
available to them. The structures of the neck are packed so tightly that nearly every lesion expresses itself as a visible or palpable bulge. In most cases,
even the most perfunctory physical examination will reveal the swelling.
Skandalakis et al.67 examined reports of 7,748 neck masses found in 232,256 surgical admissions from 1954 to 1972. Of these, 3,625 were of thyroid origin
(46.8 percent) and 4,123 were of nonthyroid origin (53.2 percent).
With a little rounding of the figures in the above study, two rules became apparent. The rules offer a well-marked pathway to diagnosis of nonthyroid neck
masses.
Rule of 80
The Rule of 80 for Neck Masses is as follows. 80 percent of:
nonthyroid masses are neoplastic
neoplastic masses are in males
neoplastic masses are malignant
malignant masses are metastatic
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metastatic masses are from primary sites above the clavicle
Rule of 7
The Rule of 7 provides a probable diagnosis of the neck mass based on the average duration of the patient's symptoms.
7 days: inflammation
7 months: neoplasm
7 years: congenital defect
AIDS (Acquired Immune Deficiency Syndrome) may have changed these numbers, since most patients will have several other groups of lymph nodes involved,
such as axillary nodes and inguinal nodes. The Rule of 80 and Rule of 7 were based on hospitalized patients with cervical lymphadenopathy. In spite of the
impossibility of such a statistical analysis being duplicated today (most patients with cervical lymphadenopathy are treated as outpatients), the authors think
that both rules remain useful and worth remembering.
The best diagnosis of primary or metastatic head and neck masses is a complete clinical evaluation and biopsy or biopsies. Lyles et al.68 and Feldman et al.69
found fine-needle aspiration reliable and safe in the management of squamous cell carcinoma of the head and neck. Lee et al.70 studied patients with
metastatic squamous carcinoma of the neck and occult primary lesion. They advised thorough evaluation prior to surgery to locate the primary tumors, and
reported that surgery, irradiation, or both can cure about 50% of patients with an unknown primary tumor.
Clonal assay of head and neck tumors was the topic of several papers from the early 1980's. We quote from Johns:71
. . .The clonogenic soft agar assay for head and neck tumor cells is a useful tool for studying their biology and growth characteristics...Ultrastructural
studies are particularly helpful in delineating the characteristics of tumor stem cells and understanding the histogenesis of neoplasms. . . Low cloning
efficiency (<0.005%) was associated with good probability of survival, whereas high cloning efficiency (0.005%) was associated with early recurrence
of cancer or death from the disease.
Johns and Mills72 elaborated on the relationship of vigorous stem cell populations, as measured by cloning efficiency, and the development of recurrences and
metastases in squamous cell carcinomas of the head and neck. Johns et al.73 reported that the human colony-forming assay test contributed to the
understanding of the cellular origins of salivary gland lesions and the chemosensitivities of salivary gland carcinomas.
THORACIC DUCT
The thoracic duct originates from the cisterna chyli and terminates in the left subclavian vein. It is from 38 to 45 cm long. The duct arises at about the level
of the 2nd lumbar vertebra from the cisterna chyli or, if the cisterna is absent (about 50 percent of cases), from the junction of the right and left lumbar
lymphatic trunks and the intestinal lymph trunk.74 It ascends on the right side of the midline on the anterior surface of the bodies of the thoracic vertebrae.
It crosses the midline between the 7th and 5th thoracic vertebrae to lie on the left side, to the left of the esophagus.
The duct passes behind the great vessels at the level of the 7th cervical vertebra, crossing ventral to the vertebral artery, and descends slightly as it
passes behind the common carotid artery to enter the left subclavian vein (Fig. 1-43) at its junction with the left internal jugular vein. The duct may have
multiple entrances to the vein, and one or more of the contributing lymphatic trunks may enter the subclavian or jugular vein independently. It can be ligated
with impunity.
Fig. 1-43.
The thoracic duct and main left lymphatic trunks. Trunks are variable and may enter the veins with the thoracic duct or separately. (Modified from Skandalakis JE,
Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
The thoracic duct collects lymph from the entire body below the diaphragm, as well as from much of the left side of the thorax. Lymph nodes may be present
at the caudal end, but there are none along its upward course. Injury to the duct in supraclavicular lymph node dissections results in copious lymphorrhea,
depletion of body fluids, and loss of proteins and electrolytes. Ligation is the answer.
Wechselberger et al.75 advocate the treatment of chronic thoracic duct fistula using a sternocleidomastoid muscle flap.
RIGHT LYMPHATIC DUCT
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RIGHT LYMPHATIC DUCT
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The right lymphatic duct —a variable structure about 1 cm long— is formed by the right jugular, transverse cervical, internal mammary, and mediastinal
lymphatic trunks (Fig. 1-44). If these trunks enter the veins separately, there is no right lymphatic duct. When present, the right lymphatic duct enters the
superior surface of the right subclavian vein at its junction with the right internal jugular vein. It drains the right side of the head, right upper limb, most of
the right side of the thorax, and the lower two-thirds of the left lung. It is the remnant of the original embryonic system of bilaterally symmetric right and left
thoracic ducts, representing the terminal part of the right thoracic duct.
Fig. 1-44.
The right lymphatic duct is formed by the junction of several lymphatic trunks. If they enter the veins separately, there may be no right lymphatic duct. (Modified from
Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Nerves of the Neck
Although the innervation of some of the anatomic entities of the neck is described in detail in this chapter, we think it is appropriate here to present a brief
summary of the nerves in general.
The nerves of the neck form a peculiar pathway from above downward, traveling all over the neck but with a definite anatomic destiny to supply the vessels
of the head, intracranial area, neck, and upper extremities. The nerves that are responsible for the innervation of some anatomic entities in the neck or other
territories, but originating in the neck, are as follows:
5 cranial nerves (VII, IX, X, XI, XII)
cervical sympathetic nerves
cervical plexus (superficial and deep)
brachial plexus
Five Cranial Nerves
The cranial nerves (VII, IX, X, XI, XII) are covered in detail in several parts of this book, such as the section on parotid glands in this chapter (facial nerve),
in the thyroid section of this chapter and in the stomach chapter (vagus nerve), and several other nerves are covered in the discussion of anatomic
complications of surgery for metastatic disease of the neck in the section on radical neck dissection. The emphasis here will be on the topography of the
ganglia of the sympathetic chain and their branches, rather than on details of the action of this system. Even though knowledge of the system has
increased, there is still much we do not know. Perhaps Sir William Turner was right when he stated, "The sympathetic begins nowhere."76
Cervical Sympathetic Nerves
The sympathetic trunk of the neck is in the prevertebral fascia between the carotid sheath in front and the longus colli and longus capitis muscles behind. It
extends above into the skull as a plexus surrounding the internal carotid artery. It is continuous, downward, with the sympathetic trunk of the thorax.
The cervical sympathetic chain is formed by three ganglia (superior, middle, and inferior) (Fig. 1-45). Each gives grey rami communicantes to the cervical
nerves, a cardiac nerve, and a plexus to an artery.
Fig. 1-45.
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The cervical sympathetic trunk. (Modified from Decker GAG, Du Plessis DJ (eds). Lee McGregor's Synopsis of Surgical Anatomy (12th ed). Bristol, England: John Wright,
1986; with permission.)
The uppermost ganglion, the superior cervical ganglion, is a reddish, flat, ellipsoidal structure. It is the largest of the three ganglia and is located just behind
the sheath of the internal carotid artery. The ganglion rests on the prevertebral fascia in the area of the transverse process of the 2nd and 3rd cervical
vertebrae. The fascia covers the longus capitis muscle.
The superior sympathetic ganglion of the neck gives grey rami communicantes to the first cervical nerves (1 to 4), forms a plexus around the external carotid
artery, gives a branch to the pharyngeal plexus, and finally gives origin to the superior cardiac nerve and the carotid nerve. McGregor and DuPlessis76 stated
that the plexus around the internal carotid artery communicates with the vagus, glossopharyngeal, and hypoglossal nerves.
Topographically the middle cervical ganglion, which is the smallest of the three (about 3 mm in diameter), is located at the level of the 6th cervical vertebra
and the cricoid cartilage. The inferior thyroid artery is an excellent landmark for the topography of this ganglion which is located anterior or posterior to the
artery. We agree with McGregor and DuPlessis that it is always present.
The middle cervical ganglion gives grey rami communicantes to the 5th and 6th cervical nerves, a plexus around the inferior thyroid artery, and the middle
cardiac nerve. It is interconnected to the inferior cervical ganglion.
The inferior cervical ganglion (cervicothoracic or stellate) is situated behind the vertebral artery, and between the transverse process of the 7th cervical
vertebra and the neck of the 1st rib, and medial to the descending branch of the costocervical branch of the subclavian artery. It is larger than the middle
ganglion but smaller than the superior cervical ganglion. It gives grey rami communicantes to C7-C8 cervical nerves; it surrounds as a plexus the subclavian
artery and its branches, and it gives origin to the inferior cardiac nerve. The 1st thoracic and inferior sympathetic ganglia are often united to form the
stellate ganglion.
Kline et al.27 discussed the topographic anatomy of the stellate ganglion:
Ansae or small rootlets enter and leave T1 and can lead the surgeon to the stellate ganglion and then the caudal portion of the thoracic sympathetic
chain. Another landmark is the vertebral artery, which can be found originating from the proximal portion of the subclavian and running upward and
medially toward the tranverse processes of C6. By elevation of the proximal portion of the vertebral artery, the stellate ganglion can usually be found
posterior to it; the rest of the thoracic sympathetic chain can be found inferior to it beneath subclavian vessels and in the upper mediastinum.
SURGICAL APPLICATIONS
Remember
The nodose ganglion (ganglion inferius) of the vagus nerve is close to the superior cervical ganglion. Anson and McVay77 stated that the ganglion should not be
excised unless its sympathetic communicating strand leads to the middle cervical ganglion; this prevents mistaking it for the nodose ganglion of the vagus nerve.
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excised unless its sympathetic communicating strand leads to the middle cervical ganglion; this prevents mistaking it for the nodose ganglion of the vagus nerve.
When the stellate ganglion (ganglion cervicothoracicum) is removed it produces Horner's syndrome (see "Anatomic Complications of Thyroidectomy"). To avoid
Horner's syndrome, carefully dissect the inferior part of the stellate ganglion.77
Removal of the stellate ganglion as well as the 1st, 2nd, 3rd, and maybe the 4th thoracic ganglia (cervicodorsal sympathectomy) is done occasionally for severe
Reynaud's phenomena (vasospastic disease of the upper extremity and severe palmar hyperhidrosis) in the hope that the pain secondary to the vascular spasm will
be alleviated.
Low anterior cervical, transaxillary, or transpleural thoracoscopic approach may be used for cervicodorsal sympathectomy.
The upper pathway of the phrenic nerve is a landmark for the location of the 5th and 6th cervical nerves during neck exploration.
The cervical sympathetic chain is located lateral to the anterior spinal ligament. Occasionally, the thorascopist confuses the ligament with the chain, and will not
perform a cervical sympathectomy. The nerve of Kuntz is a highly variable anatomic entity within the upper thorax. It is located between the root of the first thoracic
and the second thoracic intercostal nerves. The physiologic action of this ramus may relate to the sympathetic chain.78,79
Cervical Plexus
The cervical plexus (Fig. 1-46) is formed by the anterior divisions of the spinal nerves C1-C4 and is located between the middle scalenus muscle and the
levator scapula. It is covered by the SCM muscle. The branches of the cervical plexus consist of two groups: superficial and deep.
Fig. 1-46.
Superficial and deep cervical plexuses. (Modified from Healey JE Jr, Hodge J. Surgical Anatomy. Philadelphia: BC Decker, 1990; with permission.)
The superficial group (Fig. 1-47) is formed by the anterior primary divisions of cervical nerves C2, C3, and C4. The physiologic destiny of this group is
sensory. The following nerves belong to the superficial group and all of them will be seen in the vicinity of the middle part of the posterior border of the SCM
muscle, at which point the superficial plexus exits.
lesser occipital (C2)
great auricular (C2, C3)
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transverse cervical (C2, C3)
supraclavicular (C3, C4)
Fig. 1-47.
Superficial group of the cervical plexus. (Modified from Healey JE Jr, Hodge J. Surgical Anatomy. Philadelphia: BC Decker, 1990; with permission.)
The deep group (Figs. 1-46, 1-48) is motor, innervating the strap muscles of the neck and the skin and diaphragm. The branches are formed by the anterior
divisions of C1-C4 nerves. The deep group consists of the following nerves:
phrenic (C3-C5)
muscular branches to strap muscles: omohyoid, sternohyoid, sternothyroid, thyrohyoid by way of the ansa cervicalis (C1, C2, and C3)
– geniohyoid (C1)
– rectus capitis lateralis (C1)
– rectus capitis anterior (C1)
– longus capitis (C1-C4)
– longus colli (C3-C8)
– scalenus anterior (C4-C6)
– intertransversalis (C1-C8)
sternomastoid (C2, C3, or both)
levator scapulae (C3-C4)
trapezius (C3-C4 probably proprioceptive, with motor supply from XI)
scalenus medius (C3-C7)
Fig. 1-48.
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Deep group of the cervical plexus. (Modified from Healey JE Jr, Hodge J. Surgical Anatomy. Philadelphia: BC Decker, 1990; with permission.)
Brachial Plexus
The brachial plexus is formed by the anterior divisions of the four lower cervical nerves (C5-C8) with participation of the one upper thoracic nerve (T1) (Fig.
1-49). In addition, communications from C4 and T2 may also be present. It is a nerve plexus formed, subsequently, of roots, trunks, divisions, cords, and
terminal nerve branches. The brachial plexus emerges from between the anterior and middle scalene muscles, resting upon the middle scalene. The roots and
trunks are located in the neck and are related to the subclavian artery. To be more specific the plexus is in the posterior triangle of the neck: it is adjacent
to the clavicle, sternocleidomastoid muscle, and anterior scalene muscle; it rests on the middle scalene muscle.
Fig. 1-49.
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Schema of the brachial plexus.
As the nerves of the plexus emerge from between the anterior and middle scalene muscles they become ensheathed with the prevertebral fascia covering the
muscles. This connective tissue investment becomes the axillary sheath which can be injected with anesthetic in surgical procedures of the upper limb.
SURGICAL APPLICATIONS
The brachial plexus in the neck may be palpable in an angle formed between the clavicle and the lower lateral border of the SCM muscle.
The brachial plexus in the neck is related to the following anatomic entities from superficial to deep:
– Anterior
skin
superficial fascia and platysma
branches of supraclavicular nerves
deep fascia (roof of posterior triangle)
external jugular vein and some of its tributaries
omohyoid: posterior belly
transverse cervical artery
nerve to subclavius muscle
third part of subclavian artery in front of the lowest trunk
suprascapular artery
clavicle
– Posterior
middle scalene muscle
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long thoracic nerve
– Inferior
The lowest trunk lies on the first rib, marking it, sandwiched between the subclavian artery in front and the middle scalene behind.
The dorsal scapular artery often (50%) passes between the trunks of the plexus.
Platzer80 categorizes the injuries of the brachial plexus into upper and lower divisions. Injury to the upper plexus can cause Duchenne-Erb paralysis involving
movements of the shoulder joint due to injuries of the roots of C5 and C6 and with secondary involvement of the abductors, lateral rotators of the shoulder joint, and
flexors of the elbow joint and supinator muscle. There may be some disturbance of sensibility at the shoulder and at the radial side of the forearm.
Erb's point (Figs. 1-50, 1-51) is the junction of several nerves. Here the upper trunk of the brachial plexus is formed by the union of the 5th and 6th roots of the
brachial plexus. This very short upper trunk bifurcates forming anterior and posterior divisions. The suprascapular and subclavian nerves are direct branches from the
upper trunk just beyond Erb's point.
Fig. 1-50.
Schema of the formation of the brachial plexus, and its branches in the neck. The twigs to the longus and scalene muscles are not shown.
Fig. 1-51.
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The dotted circle is Erb's point. Meeting are the following nerves: A and B, the fifth and sixth roots of the brachial plexus going to form C, the upper trunk of the
brachial plexus; D and E, anterior and posterior divisions of the upper trunk; F, suprascapular nerve; G, nerve to subclavius muscle.
If the upper trunk at Erb's point is stretched or torn during the birth of a child, Erb's paralysis of the upper arm may result.
Erb's point is located just behind the posterior border of the SCM muscle, approximately 2-3 cm above the clavicle, in the vicinity of the transverse process of the 6th
cervical vertebra.
In a slender person with minimal adipose tissue in the neck, the supraclavicular nerve of the cervical plexus can be palpated.
Isolated injuries of the C7 middle trunk are unusual, but when they occur, adduction and medial rotation of the upper limb are weakened, and extension of the
elbow and metacarpophalangeal joint may be lost. The triceps reflex disappears.
In the lower plexus, trauma to the roots of C8 and T1 may lead to impairment of the long flexors of the fingers, the short muscles of the hand, and loss of
sensibilities at the ulnar side of the hand and forearm (Dejerine-Klumpke paralysis).
THYROID GLAND
EMBRYOGENESIS
Normal Development
The thyroid gland appears by the end of the third week as an epithelial thickening of the floor of the pharynx at the level of the first pharyngeal pouch. This,
the large median thyroid anlage, may be a diverticulum or a solid bud. Cranial growth of the tongue, together with elongation of the embryo, carries the origin
of the thyroid gland far cranial to the gland itself. The site of this origin is the foramen cecum of the adult tongue. In some individuals it is not grossly visible.
The thyroid gland remains connected with the foramen cecum by a minute, solid thyroglossal duct that passes through, or anterior to, the hyoid bone. By the
fifth week of gestation, this duct usually becomes fragmented; persistence of any portion is not unusual. In about 50 percent of the population, the duct can
be traced distally to the pyramidal lobe of the thyroid gland (Fig. 1-52).
Fig. 1-52.
Normal vestiges of thyroid gland development. None are of clinical significance, but their presence may be of concern to the surgeon. (Modified from Skandalakis JE,
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Normal vestiges of thyroid gland development. None are of clinical significance, but their presence may be of concern to the surgeon. (Modified from Skandalakis JE,
Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
The developing gland, at first an irregular plate, develops two lateral wings connected by the isthmus. Follicles appear during the second month of gestation
and increase through the fourth month. Colloid formation and uptake of radioactive iodine begin at about the eleventh week.
Epithelial structures, the paired lateral anlages, are formed from the ventral portions of the fourth and fifth branchial pouches. This structure, the well-known
ultimobranchial body (caudal pharyngeal pouch complex), becomes lost in the developing thyroid gland, and its cells become dispersed as the C (calcitonin)
cells among the thyroid follicles.
Present evidence suggests that the primary origin of the calcitonin-producing cells of the thyroid gland is the neural crest of the embryo. From the neural
crest these cells migrate to the ultimobranchial body,81 and later become part of the thyroid gland. C cells belong to a group of neural-crest derivatives
known as APUD (amine precursor uptake and decarboxylation) cells. Welbourn82 believed that tumors of these cells, medullary carcinomas, account for 6 to 8
percent of all thyroid malignancies. Several other endocrine-producing cells in the gut and tracheal walls, pancreas, and adrenal glands belong to the APUD
system. Tumors of the APUD system are collectively called "apudomas."
Congenital Anomalies
It is not within the scope of this book to present detailed anomalies or variations of the thyroid gland. The student of thyroid anatomy will find complete
coverage in Embryology for Surgeons.83 However, we will mention a few common anomalies and discuss in greater detail the lateral aberrant thyroid.
The anatomy of the abnormal is shown in Table 1-3.
Table 1-3. A Classification of Congenital Anomalies of the Thyroid Glanda
Both Median and Lateral
Anlages
Median Anlage
Lateral Anlage
Neither
Anlage
A. Variable shape and
weight
A. Agenesis
A. Nonfusion with median anlage
A. Vessels
B. Symmetry
1. Isthmus: thick, thin, absent
B. Cysts with squamous epithelial lining
1. Artery
C. Total thyroid agenesis
2. Bilobed partial
C. Solid cell rests: C cells
2. Vein
D. One lobe absent
3. Unilateral
D. Agenesis: Lobdell-DiGeorge syndrome
E. Pyramidal lobe
4. Pyramidal lobe
E. Pharyngeal pouches remnants
1. Absent
5. Short
1. Thymic
2. From the right lobe
6. Long
2. Parathyroid
3. From the left lobe
7. Right or Left
3. Ultimobranchial body
4. From the isthmus
8. Thyroglossal duct
B. Anomalies of descent along the thyroid line
1. Lingual
3. Lymph
B. Muscles
C. Nerves
F. Ectopic thyroid tissue in fat, muscles
G. Fat, muscle cartilage within the thyroid gland
H. Lateral aberrant thyroid not within the capsule of medially located
lymph nodes
2. Sublingual
3. Prelaryngeal
C. Accessory ectopic (i.e., outside the pathway of
descent)
1. Mediastinal
2. Intratracheal
3. Lateral to jugular
4. Ovarian
5. Sella turcica
6. Retrotracheal
7. Preaortic
8. Pericardial
9. Cardiac
10. Porta hepatis
11. Gallbladder
12. Groin
13. Intralaryngeal
14. Intraesophageal
15. Intralymph node
a This
classification is based on the thyroid anlage(s), if any, involving the anomaly.
Source: Skandalakis JE, Gray SW (eds). Embryology for Surgeons, 2nd Ed. Baltimore: Williams & Wilkins, 1994; with permission.
Lingual Thyroid
Occasionally the thyroid gland is not in the normal cervical position, but lies beneath the epithelium of the tongue, at the site of the foramen cecum. LiVolsi84
stated that lingual thyroid (Fig. 1-53) results from a failure of the median anlage to descend from the pharynx.
Fig. 1-53.
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The embryonic path of descent of the thyroid gland. An ectopic thyroid may remain at its level of origin in the tongue, or its descent may be interrupted at any point
along the pathway. Hyperdescent into the thorax (primarily retrosternal thyroid) is also possible. (Modified from Gray SW, Skandalakis JE, Akin JT Jr. Embryological
considerations of thyroid surgery: Developmental anatomy of the thyroid, parathyroid, and the recurrent laryngeal nerve. Am Surg 1976;42:621-628; with
permission.)
The lingual thyroid gland is usually small but normal and is the only thyroid tissue present. Radioactive iodine scintigraphy will aid in the diagnosis and will
determine the presence of other thyroid tissue in the patient.
A thyroid gland may be found anywhere along the track from the foramen cecum to the normal site. Such "partially descended" glands are rare.85
Total excision of a lingual thyroid is necessary. It requires care, because the gland is well vascularized by the lingual arteries. In one series,86 2 out of 12
lingual thyroids were malignant. If no malignancy is reported from frozen sections, the excised tissue can be implanted into the anterior abdominal wall.
Read an Editorial Comment
Persistent Remnants of the Thyroglossal Duct
The foramen cecum of the tongue and the pyramidal lobe of the thyroid gland are normal remnants of the thyroglossal duct. Thyroglossal duct cysts account
for 62.8 percent of all the congenital masses of the neck.87 Of those, according to LiVolsi,88 up to 62 percent contain ectopic thyroid tissue. Primary
carcinoma in thyroglossal duct cyst occurs in less than 1 percent of cases.89,90 Walton and Koch91 presented a case of thyroglossal duct cyst with papillary
carcinoma, and indicated that fewer than 150 cases have been reported. Table 1-4 shows histologic composition and other characteristics of thyroglossal
duct-associated carcinoma in 109 cases. Medullary thyroid cancer has not been reported because there are no C cells in the pyramidal lobe (the parafollicular
C cells arise from the lateral thyroid anlage). Embryology and pathology are in full agreement here.
Table 1-4. Reported Cases of Thyroglossal Duct-Associated Carcinomaa
Histology:
Papillary carcinoma
99
Adenocarcinoma
2
Malignant struma
1
Squamous cells carcinoma
7
Total (reported cases)
109
Female/Male
66:42 (1 unknown)
Age
6 to 81 years
History of neck radiation
a
3
Adapted from LiVolsi VA. Surgical Pathology of the Thyroid. Philadelphia: WB Saunders, 1990.
Source: Skandalakis JE, Gray SW (eds). Embryology for Surgeons, 2nd Ed. Baltimore: Williams & Wilkins, 1994; with permission.
Frequently, individuals who have ectopic thyroid also have an absence of normal thyroid. Therefore, before the ectopic thyroid is excised, it is important to
evaluate whether it is the only thyroid tissue in the body.92
Between the foramen cecum and the pyramidal lobe is a very small epithelial tube, usually broken in several places. Occasionally these epithelial fragments
hypertrophy, secrete fluid, and form cysts. Drainage or aspiration of these cysts is futile and often results in the formation of a fistula, which usually
becomes infected.
All fragments of the duct, foramen cecum, and midportion of the hyoid bone should be removed (Sistrunk procedure). Recurrence of the cyst is the result of
failure to remove the entire duct. Failure to remove the central portion of the hyoid bone resulted in 17 percent recurrence in one series of operations.93 No
nerve, blood vessel, or organ need be injured in this procedure. Quigley et al.94 warned against inadvertent removal of a partially descended thyroid gland
mistaken for a thyroglossal duct cyst.
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Accessory Ectopic Thyroid Tissue
Figure 1-54 demonstrates not only the possible sites of ectopic tissue but also tissues of other anatomic entities within the thyroid parenchyma.
Fig. 1-54.
Left side of drawing illustrates possible sites of accessory ectopic thyroid tissue. Right side of illustration lists other anatomic entities from which tissue may be found
within the thyroid. (Modified from Skandalakis JE, Gray SW. Embryology for Surgeons (2nd ed). Baltimore: Williams & Wilkins, 1994; with permission.)
Bhatnagar et al.95 described an accessory lobe of the thyroid gland located inferior to both lateral lobes and the isthmus. Its arterial supply originated from
the right inferior thyroid artery and its vein drained via the plexus thyroideus impar.
Monchik and Materazzi96 advised that posterior or aberrant mediastinal thyroid masses may require a thoracic surgical approach.
Kumar et al.97 reported an adolescent with dual ectopic thyroid glands located in the sublingual and subhyoid regions, the seventh such case in the
literature.
LATERAL ABERRANT THYROID
Of special interest —and a vexation to surgeon, pathologist, and patient— is lateral aberrant thyroid tissue; that is, tissue located lateral to the jugular
vein.98 It has three morphologic manifestations.
This tissue may be found as a nodule attached by connective tissue to the mother gland. These thyroid tissue "islands," which pull away from the visceral
body during development, are nevertheless normal.
The second site for lateral thyroid tissue is within lymph nodes or their remnants. We should consider a cervical lymph node containing thyroid follicles to be
clinically a metastatic thyroid carcinoma. However, the existence of heterotopic thyroid tissue within cervical glands has been reported. Six such cases of
normal thyroid gland at 5-Ìm sections were described by Sawicki et al.99
The final morphologic expression of laterally aberrant thyroid tissue must be termed congenital. Rubenfeld et al.100 reported a patient whose only thyroid
tissue, by all appearances, was lateral aberrant thyroid tissue.
Always consider the possibility of metastatic thyroid cancer of lateral aberrant thyroid nodules.
STRUMA OVARII
Struma ovarii, the ovarian thyroid, is an extraordinary thyroid ectopia, although it is unrelated to the anatomic thyroid gland and is not a true congenital
anomaly. Ovarian thyroid tissue is a fellow traveller with dermoid cysts and teratoma. According to estimates of Woodruff et al.,101 struma ovarii may exist in
0.2-1.3% of all ovarian tumors. Of these, 5-6% are bilateral and about 5% possess functioning thyroid tissue. Kempers et al.102 found hyperthyroidism in
struma ovarii. Malignancy is a possible occurrence in as many as 5% of all struma ovarii,103 with metastasis noted in papillary carcinoma.98,104
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SURGICAL ANATOMY
General Topography
The thyroid gland consists typically of two lobes, a connecting isthmus, and an ascending pyramidal lobe. One lobe, usually the right, may be smaller than the
other (7 percent) or may even be completely absent (1.7 percent). The isthmus is absent in about 10 percent of thyroid glands, and the pyramidal lobe is
absent in about 50 percent (see Fig. 1-52). A minute epithelial tube or fibrous cord, the thyroglossal duct, almost always extends between the thyroid gland
and the foramen cecum of the tongue.
The thyroid gland normally extends from the level of the 5th cervical vertebra to the body of the 1st thoracic vertebra. It may lie higher (lingual thyroid), but
rarely lower.105
The normal thyroid gland weighs about 30 g in the adult —somewhat more in females than in males. Each lobe is approximately 5 cm in length, 3 cm at its
greatest width, and 2-3 cm thick.106 The isthmus connecting the two lobes is about 1.3 cm in breadth. The lobes have a broad lower portion and a relatively
conical apex.
Capsule of the Thyroid Gland
Like many other organs, the thyroid gland has a connective tissue capsule which is continuous with the septa, and which makes up the stroma of the organ.
This is the true capsule of the thyroid.
External to the true capsule is a well developed (to a lesser or greater degree) layer of fascia derived from the pretracheal fascia. This is the false capsule,
also called the perithyroid sheath or surgical capsule. Anteriorly and laterally this fascia is well developed; posteriorly it is thin and loose, permitting
enlargement of the thyroid gland posteriorly. There is a thickening of the fascia that fixes the back of each lobe to the cricoid cartilage. Such thickenings are
the ligaments of Berry. The false capsule, or fascia, is not removed with the gland during thyroidectomy.
The superior parathyroid glands normally lie between the true capsule of the thyroid and the fascial false capsule. The inferior parathyroids may be between
the true and false capsules, within the thyroid parenchyma, or lying on the outer surface of the fascia. The levator muscle of the thyroid is one or more
muscular slips that occasionally connect the hyoid bone with the thyroid gland. These vestigial muscles are inconstant in occurrence, location, and
innervation. They have been divided into anterior, lateral, and posterior levators.
Vascular Supply
The thyroid gland competes with the adrenal glands for having the greatest blood supply per gram of tissue.107 One consequence is that hemostasis is a
major problem of thyroid surgery, especially in patients with toxic goiter.
Arteries
Two paired arteries, the superior and inferior thyroid arteries, and an inconstant midline vessel, the thyroid ima artery, supply the thyroid (Fig. 1-55).
Fig. 1-55.
The arterial supply to the thyroid gland. The thyroid ima artery is only occasionally present. (Modified from Tzinas S, Droulias C, Harlaftis N, Akin JT Jr, Gray SW,
Skandalakis JE. Vascular patterns of the thyroid gland. Am Surg 1976;42:639-644; with permission.)
SUPERIOR THYROID ARTERY
The superior thyroid artery arises from the external carotid artery just above, at, or just below the bifurcation of the common carotid artery. It passes
downward and anteriorly to reach the superior pole of the thyroid gland. In part of its course, the artery parallels the external branch of the superior
laryngeal nerve which supplies the cricothyroid muscle and the cricopharyngeus muscle, the lowest voluntary part of the pharyngeal musculature.
There are six branches of the superior thyroid artery (Fig. 1-56): the infrahyoid, sternocleidomastoid, superior laryngeal, cricothyroid, inferior pharyngeal
constrictor, and terminal branches of the artery for the blood supply of the thyroid and parathyroid glands. Usually there are two branches to the thyroid —
the anterior and posterior— but occasionally there may be a third, the so-called lateral branch (Fig. 1-56).
Fig. 1-56.
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Branches of the superior thyroid artery. (Modified from Montgomery RL. Head and Neck Anatomy: With Clinical Correlations. New York: McGraw-Hill, 1981; with
permission.)
At the superior pole, the superior thyroid artery divides into anterior and posterior branches. The anterior branch anastomoses with the contralateral
artery;108 the posterior branch anastomoses with branches of the inferior thyroid artery. From the posterior branch, a small parathyroid artery passes to the
superior parathyroid gland.
In a study of thyroid glands removed at autopsy from Japanese patients, Nobori et al.109 observed that an anastomosing vessel from the posterior branch of
the superior thyroid artery supplied the superior parathyroid in 45% of cases. The majority of 92 glands (67%) had a single artery of supply; 1/3 had two or
more small vessels which entered the gland. In the photographs of the specimens, the branching pattern of the primary vessel supplying the gland appeared
to indicate that its origin was from the superior thyroid artery.
Weiglein110 reported a rare variation of blood supply to the thyroid gland. In this case, the right inferior thyroid artery was replaced by an artery originating
from the right internal thoracic artery. The left inferior thyroid artery was replaced by an artery arising from the vertebral artery.
INFERIOR THYROID ARTERY
The inferior thyroid artery usually arises from the thyrocervical trunk, but in about 15 percent of individuals it arises directly from the subclavian artery.111
The inferior thyroid artery ascends behind the carotid artery and the internal jugular vein, passing medially and posteriorly on the anterior surface of the
longus coli muscle. After piercing the prevertebral fascia, the artery divides into two or more branches as it crosses the ascending recurrent laryngeal nerve.
The recurrent laryngeal nerve may pass anterior or posterior to the artery, or between its branches (Fig. 1-57). The lowest branch sends a twig to the
inferior parathyroid gland and supplies the lower pole of the thyroid gland. The upper branch supplies the posterior surface of the gland, usually anastomosing
with a descending branch of the superior thyroid artery. On the right, the inferior thyroid artery is absent in about 2 percent of individuals. On the left, it is
absent in about 5 percent (Hunt et al.).112 The artery is occasionally double.113
Fig. 1-57.
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Relations at the crossing of the recurrent laryngeal nerve and the inferior thyroid artery. A-C, Common variations. Their frequencies are given in Table 1-9. D, A
nonrecurrent nerve is not related to the inferior thyroid artery. E, The nerve loops beneath the artery. (Modified from Tzinas S, Droulias C, Harlaftis N, Akin JT Jr, Gray
SW, Skandalakis JE. Vascular patterns of the thyroid gland. Am Surg 1976;42:639-644; with permission.)
THYROID IMA ARTERY
The thyroid ima artery is unpaired and inconstant. It arises from the brachiocephalic artery, the right common carotid artery, or the aortic arch. It occurs in
about 10 percent of individuals, according to Montgomery.41 It may be as large as an inferior thyroid artery or it may be a mere twig. Its position anterior to
the trachea makes it important in tracheostomy.
Veins
Veins of the thyroid gland form a plexus of vessels lying in the substance and on the surface of the gland. The plexus is drained by three pairs of veins, the
superior, middle, and inferior thyroid veins (Fig. 1-58).
Fig. 1-58.
The venous drainage of the thyroid gland. The inferior thyroid veins are quite variable. (Modified from Tzinas S, Droulias C, Harlaftis N, Akin JT Jr, Gray SW,
Skandalakis JE. Vascular patterns of the thyroid gland. Am Surg 1976;42:639-644; with permission.)
SUPERIOR THYROID VEIN
The superior thyroid vein accompanies the superior thyroid artery. Emerging from the superior pole of the thyroid, the vein passes superiorly and laterally
across the omohyoid muscle and the common carotid artery to enter the internal jugular vein alone or with the common facial vein.
MIDDLE THYROID VEIN
The middle thyroid vein arises on the lateral surface of the gland at about two-thirds of its anteroposterior extent. No artery accompanies it. It crosses the
common carotid artery to open into the internal jugular vein. This vein may be absent or, occasionally, double. The extra vein is inferior to the normal one; it
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common carotid artery to open into the internal jugular vein. This vein may be absent or, occasionally, double. The extra vein is inferior to the normal one; it
has been called the "fourth" thyroid vein. The importance of these middle thyroid veins is in their vulnerability during thyroidectomy.
INFERIOR THYROID VEIN
The inferior thyroid vein is the largest and most variable of the thyroid veins; the right and left sides are usually asymmetric. The right vein leaves the lower
border of the thyroid gland, passes anterior to the brachiocephalic artery, and enters the right brachiocephalic vein. The left vein crosses the trachea to
enter the left brachiocephalic vein. Rarely, the right vein crosses the trachea to enter the left brachiocephalic vein, sometimes forming a common trunk with
the left vein. This common trunk is called the thyroid ima vein.
Lymphatics
Several broad patterns of lymphatic drainage of the thyroid gland have been proposed (Fig. 1-59). Each conceptualization is based on the same facts; each
is correct. We will follow that of Hollinshead36 (Fig. 1-59C). The actual drainage is shown in Fig. 1-60.
Fig. 1-59.
Three concepts of the lymphatic drainage of the thyroid gland. A, Edis et al.352 B, McGregor and DuPlessis.76 C, Hollinshead.36 All three concepts are correct and
based on the same facts. (Modified from Tzinas S, Droulias C, Harlaftis N, Akin JT Jr, Gray SW, Skandalakis JE. Vascular patterns of the thyroid gland. Am Surg
1976;42:639-644; with permission.)
Fig. 1-60.
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The lymph nodes receiving drainage from the thyroid gland. After the description of Rouviere.359 (Modified from Tzinas S, Droulias C, Harlaftis N, Akin JT Jr, Gray SW,
Skandalakis JE. Vascular patterns of the thyroid gland. Am Surg 1976;42:639-644; with permission.)
PATTERNS OF DRAINAGE
Median Superior Drainage
Three to six vessels arise from the superior margin of the isthmus and from the medial margins of the lateral lobes. These vessels pass upward in front of the
larynx to end in the digastric lymph nodes. Some vessels may enter one or more prelaryngeal ("Delphian") nodes just above the isthmus. Secondary drainage
may be to upper jugular nodes on either side or to pretracheal nodes below the thyroid by a vessel passing from the Delphian nodes downward over the front
of the thyroid.
It has been suggested that there is a connection between the lymphatic drainage of the superior thyroid artery and the orbit by way of the jugular chain of
cervical lymph nodes.114 In neither the orbit nor the eye itself can lymphatic vessels be demonstrated.115 The immediate cause of exophthalmus associated
with thyroid disease is the enlargement of the extraocular muscles, especially the inferior rectus and inferior oblique. Thyroid antigen or antigen-antibody
complexes reaching the eye from the thyroid gland produce an autoimmune response in the extraocular muscles.
Median Inferior Drainage
Several lymph vessels drain the lower part of the isthmus and the lower medial portions of the lateral lobes. They follow the inferior thyroid veins to end in
the pretracheal and brachiocephalic nodes.
Right and Left Lateral Drainage
Lymphatic trunks arise from the lateral border of each lobe. Superiorly they pass upward with the superior thyroid artery and vein. Inferiorly they follow the
inferior thyroid artery. Between these two groups, some vessels pass laterally, anteriorly, or posteriorly to the carotid sheath to reach the lymph nodes of
the internal jugular chain. Occasionally, such vessels drain into the right subclavian vein, jugular vein, or thoracic duct without passing through a lymph
node.116
Posterior Drainage
Posterior lymphatic vessels arise from the inferomedial surfaces of the lateral lobes to drain into nodes along the recurrent laryngeal nerve. Occasionally, a
posterior ascending trunk from the upper part of the lobe reaches the retropharyngeal nodes.
METASTATIC SPREAD
A representation of lymph node regions of importance for management of thyroid carcinoma is seen in Fig. 1-61. Lymph node groups at the highest risk for
regional metastasis from differentiated thyroid carcinoma are shown in Fig. 1-62.
Fig. 1-61.
Lymph node regions of importance for management of thyroid carcinoma. (Modified from Callender DL, Sherman SI, Gagel RF, Burgess MA, Goepfert H. Cancer of the
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Lymph node regions of importance for management of thyroid carcinoma. (Modified from Callender DL, Sherman SI, Gagel RF, Burgess MA, Goepfert H. Cancer of the
thyroid. In: Myers EN, Suen JY (eds). Cancer of the Head and Neck (3rd ed). Philadelphia: WB Saunders, 1996, p. 485-515; with permission.)
Fig. 1-62.
Diagram illustrating lymph node groups at highest risk for regional metastasis from differentiated thyroid carcinoma. (Modified from Goepfert H, Callender DL.
Differentiated thyroid cancer – papillary and follicular carcinoma. Am J Otolaryngol 1994;15:167-179; with permission.)
A study by Gemsenjäger et al.117 of patients with differentiated thyroid carcinoma concluded that papillary carcinoma pT1-3 N0 M0 and minimally invasive
follicular carcinoma without nodal or distant metastasis can be adequately treated with hemithyroidectomy or total thyroidectomy only and without
radioiodine, while all the other tumors such as invasive follicular cancer were treated adequately with total bilateral lobectomy and radioiodine.
Feind118 found metastatic involvement of middle jugular lymph nodes in 85 of 111 specimens from patients with thyroid carcinoma. In 67 of these, lower
jugular nodes were positive. Submandibular and mediastinal nodes were rarely affected.
Table 1-5, based on more than 1,000 patients of Shaha et al.,119 summarizes the incidence of nodal metastasis and distant metastasis in differentiated
thyroid carcinoma. Shaha et al. concluded that the risk of nodal and distant metastasis varies considerably based on individual histologic variety.
Table 1-5. Incidence of Metastasis in Thyroid Carcinoma
Nodal Metastasis
Distant Metastasis
Papillary
61%
10%
Follicular
30%
22%
Hurthle cell
21%
33%
Source: Data from Shaha AR, Shah JP, Loree TR. Patterns of nodal and distant metastasis based on histologic varieties in differentiated carcinoma of the thyroid. Am J
Surg 172:692-694, 1996.
Read an Editorial Comment
Innervation
The thyroid gland is innervated by the sympathetic system from the superior, middle, and inferior ganglia of the cervical chain. But in thyroid surgery the
recurrent and superior laryngeal nerves of the parasympathetic (vagus) system (which play no role in the innervation of the gland) are of utmost importance,
so we consider them here.
Recurrent Laryngeal Nerves (Inferior Laryngeal)
NORMAL ANATOMY
The right and left recurrent laryngeal nerves are intimately related to the thyroid gland. The right recurrent nerve branches from the vagus as it crosses
anterior to the right subclavian artery. The right recurrent nerve (Fig. 1-63B) loops around the subclavian artery from posterior to anterior, crosses behind
the right common carotid and ascends in or near the tracheoesophageal groove. It passes posterior to the right lobe of the thyroid gland to enter the larynx
behind the cricothyroid articulation and the inferior cornu of the thyroid cartilage.
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Fig. 1-63.
The embryonic aortic arches and the "recurrence" of the laryngeal nerve. A, Normal embryo with third, fourth, and sixth aortic arches present. The laryngeal nerve
arises from the vagus nerve and passes under and behind the sixth aortic arch. B, Normal adult. On the right, the laryngeal nerve passes under the subclavian
artery; on the left, it passes under the ligamentum arteriosum. C, In the presence of a retroesophageal right subclavian artery, the nerve passes to the larynx
without "recurring." D, In the presence of a right aortic arch, the right nerve loops under the arch; the left nerve passes directly to the larynx. C and D are
encountered in less than 1 percent of specimens. (Modified from Skandalakis JE, Droulias C, Harlaftis N, Tzinas S, Gray SW, Akin JT Jr. Recurrent laryngeal nerves. Am
Surg 1976;42:629-634; with permission.)
The left recurrent nerve arises where the vagus nerve crosses the aortic arch, just distal to the origin of the left subclavian artery from the aortic arch. It
loops under the ligamentum arteriosum and the aorta, and ascends in the same manner as the right nerve. Both nerves cross the inferior thyroid arteries near
the lower border of the middle third of the gland.
VARIATIONS
Several variations may occur in the courses of the recurrent nerves. All serve to increase the possibility of injury to the nerve during thyroid surgery.
Katz and Nemiroff 120 visualized 1,117 recurrent laryngeal nerves. They reported that 747 (63%) bifurcated or trifurcated more than 0.5 cm from the cricoid
cartilage. Bilateral nerve bifurcation was observed in 170 patients.
In an earlier version of this research, these authors wisely concluded that "extralaryngeal branches of the recurrent laryngeal nerve are not an anatomic
rarity. Therefore, thyroid surgery must include identification and preservation of the recurrent laryngeal nerve and all of its divisions."121
In about 1 percent of patients, the right recurrent nerve arises normally from the vagus, but passes medially almost directly from its origin to the larynx
without looping under the subclavian artery (Fig. 1-63C). In these cases, the right subclavian artery arises from the descending aorta and passes to the right
behind the esophagus. This anomaly is asymptomatic, and the thyroid surgeon will rarely be aware of it prior to operation. Even less common is a
nonrecurrent left nerve in the presence of a right aortic arch and a retroesophageal left subclavian artery (Fig. 1-63D).
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In the lower third of its course, the recurrent laryngeal nerve ascends behind the pretracheal fascia at a slight angle to the tracheoesophageal groove. In the
middle third of its course, the nerve may lie in the groove, medial to the suspensory ligament of the thyroid gland (ligament of Berry), within the ligament, or
within the substance of the thyroid gland.
Skandalakis et al.122 examined the course of the recurrent laryngeal nerve in 102 cadavers (204 sides). In about half of the specimens, the nerve lay in the
tracheoesophageal groove. In the other half, most were anterior to the groove (paratracheal); a few lay posterior (paraesophageal). In 8 of the 204 sides,
the nerve lay within the gland (Fig. 1-64). Other workers have found a slightly higher percentage of intraglandular nerves.123
Fig. 1-64.
The course of the recurrent laryngeal nerve at the thyroid gland in 102 cadavers. About half the nerves were found in the groove between the trachea and the
esophagus. A, Lateral view. B, Cross-sectional view. (Modified from Skandalakis JE, Droulias C, Harlaftis N, Tzinas S, Gray SW, Akin JT Jr. Recurrent laryngeal nerves.
Am Surg 1976;42:629-634; with permission.)
Read an Editorial Comment
The senior author of this chapter (JES) feels very strongly that the "recurrent laryngeal nerve" should be named or renamed the inferior laryngeal nerve.
We quote from Schweizer and Dörfl124:
[I]t is particularly interesting for laryngeal surgeons to notice the minor variability of branching of the inferior laryngeal nerve and of its mode of
entrance into the hypopharynx. Even in the case of a unilateral single trunk, the nerve passes just behind the cricothyroid joint and can be easily
identified. Variations...were mainly limited to the level of the extralaryngeal division of the inferior laryngeal nerve. Thus, the surgeon can rely on
precise and consistent landmarks in this part of the body, as in other anatomical locations.
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precise and consistent landmarks in this part of the body, as in other anatomical locations.
The recurrent laryngeal nerve is safest and least visible when it lies in the tracheoesophageal groove. It is most vulnerable when it traverses the thyroid
parenchyma. Where it runs in the suspensory ligament of the thyroid, it must be identified and protected before the ligament is divided.
The recurrent laryngeal nerve crosses the inferior thyroid artery at the middle third of the gland. It may lie anterior or posterior to, or between the branches
of the artery.125 Lekacos et al.126 reported that most recurrent laryngeal nerves (approximately 80%) are located either posterior to or between the
branches of the inferior thyroid artery. The three major types of crossings were shown previously in Fig. 1-57A-C. A series by Skandalakis et al.122 showed
that the right nerve most frequently lay between arterial branches (48 percent); the left nerve was usually behind the artery (64 percent). Table 1-6 shows
the relative incidence of the types of crossing. No one pattern can be considered "normal"; the surgeon must be prepared for any configuration of artery and
nerve.
Table 1-6. Relationship of Recurrent Laryngeal Nerve and Inferior Thyroid Artery
Per Cent Frequency
102 Cadavers
1246 Cases From Literature
Relation
Right Left
Both Sides Both Sides
Nerve anterior to artery
31.4
9.8
20.6
21.1
Nerve posterior to artery
19.6
63.7
41.6
50.4
Nerve between branches of artery 48.0
26.5
37.3
24.8
Nonrecurrent nerve and other
–
0.5
3.6
1.0
100.0 100.0 100.0
100.0
Source: Skandalakis JE, Droulias C, Harlaftis N, Tzinas S, Gray SW, Akin JT Jr. The recurrent laryngeal nerve. Am Surg 42(9):629-634, 1976; with permission.
Kreyer and Pomaroli127 reported an anastomosis between the external branch of the superior laryngeal nerve and the recurrent laryngeal nerve.
Sturniolo et al.128 emphasized that the secret to avoiding injury to the recurrent laryngeal nerve during thyroid surgery is as follows: (1) deep knowledge of
the surgical anatomy of the thyroid region; (2) total extracapsular thyroidectomy; (3) a thorough search, identification, and exposure of the nerve itself; and
(4) following the course of the nerve with care.
According to Procacciante and colleagues,129 after the recurrent laryngeal nerve is made taut by upward and medial traction of the thyroid, it may be
palpated caudally to the inferior pole of the gland. This maneuver aided safe dissection in the region of the inferior thyroid artery.
Marchesi et al.130 reported an occurrence rate of 0.34% for a nonrecurrent inferior laryngeal nerve on the right side, and extreme rarity on the left side.
They report seven cases of nonrecurrent laryngeal nerve, and emphasize the diagnostic accuracy of angio-MR for the anatomic identification of the vascular
anomaly that invariably occurs with the nerve malformation.
The nonrecurrent nerve (left or right, when present) may pass directly to the larynx with no relation to the inferior thyroid artery (Fig. 1-57D), or such a
nerve may loop around the artery (Fig. 1-57E).
Avisse et al.131 reported 17 cases of a right nonrecurrent inferior laryngeal nerve. In two of these cases an aberrant right subclavian artery coexisted with a
nonrecurrent inferior laryngeal nerve.
Sanders et al.,132 who found seven cases of nonrecurrent laryngeal nerves in 1,000 thyroidectomies, reported the following:
In two of these seven cases, both a nonrecurrent nerve and an additional recurrent branch were present on the right side. This double nerve
presentation has not been described before. Unless one is aware of this possibility, one might inadvertently injure the major nonrecurrent trunk, having
identified only a small recurrent branch. We emphasize the need for a complete nerve identification technique.
Miyauchi et al.133 reported good results with simple neurorrhaphy or with graft (vagus nerve - ansa cervicalis) of the injured recurrent nerve. Their 8 patients
recovered from hoarseness, and maximum phonation improved. Steinberg et al.134 stated that branches of the recurrent laryngeal nerve (motor as well as
sensory), together with sympathetic nerves, supply the larynx beneath the cords, pharynx, cervical esophagus, and cervical trachea.
EXPOSURE
Exposure of the recurrent nerve during any procedure on the thyroid is a sound surgical principle and should be done wherever possible. If the nerve cannot
be found readily, the surgeon must avoid the areas in which it may be hidden. Fibrosis, increased bleeding, and lack of clear anatomic relationships are
responsible for most nerve injuries. Postoperative exploration for hemorrhage also is associated with a higher risk of nerve injury.135
At one time the recurrent nerve was considered so delicate that "if a recurrent laryngeal nerve is seen during thyroidectomy, it is injured."136 At the other
extreme are those who would require demonstration of the nerve by direct stimulation during laryngoscopic observation of the vocal cords.137 We believe
that visual identification, with avoidance of traction, compression, or stripping the connective tissue is all that is necessary. Complete anatomic dissection is
not required, but simple exposure will not destroy it. From their investigation of 803 goiter operations and a literature search, Jatzko et al.138 noted a
significantly higher rate of injury to the recurrent laryngeal nerve when it was not identified (5.2%) than when it was exposed (1.2%).
The recurrent laryngeal nerve forms the medial border of a triangle bounded superiorly by the inferior thyroid artery and laterally by the common carotid
artery. The nerve can be identified where it enters the larynx just posterior to the inferior cornu of the thyroid cartilage.139 If the nerve is not found, a
nonrecurrent nerve should be suspected, especially on the right.
Pelizzo et al.140 advised that the best way to locate the recurrent laryngeal nerve during thyroidectomy is the Zuckerkandl's tuberculum, which is located on
the lateral portion of each of the thyroid lobes, and according to these authors is the constant anatomic landmark when present (Fig. 1-65)
Fig. 1-65.
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Fig. 1-65.
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Zuckerkandl's tuberculum size. 0, unrecognizable; 1, only a thickening of the lateral edge of the thyroid lobe; 2, smaller than 1 cm; 3, larger than 1 cm. (Modified
from Pelizzo MR, Toniato A, Gemo G. Zuckerkandl's tuberculum: an arrow pointing to the recurrent laryngeal nerve (constant anatomical landmark). J Am Coll Surg
1998;187:333-336, 1998; with permission.)
The tubercle of Zuckerkandl is the most posterior extension of the lateral lobes of the thyroid gland at the level of the ligament of Berry141,142 (Fig. 1-66).
Fig. 1-66.
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The region of the tubercle of Zuckerkandl (the most posterior extent of the thyroid lobe) and the distal course of the recurrent laryngeal nerve (RLN). The relation of
the RLN to the remaining remnant of thyroid and mechanism for possible RLN injury are shown. (Modified from Thompson NW. Thyroid gland. In: Greenfield LJ (ed).
Surgery: Scientific Principles and Practice (2nd ed). Philadelphia: Lippincott-Raven, 1997, pp. 1283-1308; with permission.)
To digress for a moment, I (JES), the senior author of this chapter, would like to point out that never in my 50 years in the anatomy lab and operating room
did I notice the tubercle of Zuckerkandl. To my embarrassment and frustration, I had not heard of this specific protuberance of the thyroid lobe until I read
the previously mentioned excellent publication by Pelizzo et al.140
In the lower portion of the course of the recurrent laryngeal nerve, the nerve can be palpated as a tight strand over the tracheal surface. There is more
connective tissue between the nerve and the trachea on the right than on the left.
Superior Laryngeal Nerve
The superior laryngeal nerve arises from the vagus nerve just inferior to its lower sensory ganglion just outside the jugular foramen of the skull. The nerve
passes inferiorly, medial to the carotid artery. At the level of the superior cornu of the hyoid bone it divides into a large, sensory, internal laryngeal branch
and a smaller, motor, external laryngeal branch, serving the cricothyroid muscle143 and the cricopharyngeus. The point of division is usually within the
bifurcation of the common carotid artery (Fig. 1-67).
Fig. 1-67.
Branching of the superior laryngeal nerve and the carotid arteries. A, The internal branch crosses the external carotid artery above the origin of the lingual artery. B,
The internal branch crosses below the origin of the lingual artery. C, The nerve divides medial to the external carotid artery. (Modified from Droulias C, Tzinas S,
Harlaftis N, Akin JT Jr, Gray SW, Skandalakis JE. The superior laryngeal nerve. Am Surg 1976;42:635-638; with permission.)
Sun and Dong144 dissected 60 adult cadavers (120 superior laryngeal nerves) and reported the morphology and topography of the superior laryngeal nerve,
its branches, its anastomoses with the cervical sympathetic, and its relations to the thyroid gland. An anastomotic loop connecting the cervical sympathetic
chain and the distal laryngeal nerve was present in 111 of the 120 cases. The morphology of this loop made it possible to define five different types. Figures
1-68 and 1-69 are from their interesting paper, and we urge all surgeons who perform thyroid surgery to read it.
Fig. 1-68.
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The sketch of the coronal section of the larynx shows the superior laryngeal nerve trunk(s) in the environment of the sternothyroid-laryngeal triangle, which is
bounded laterally by the sternothyroid muscle, medially by the inferior pharyngeal constrictor and cricothyroid muscles, and inferiorly by the superior pole of the
thyroid gland. a, single nerve trunk, 89 sides (74.2%); b, single nerve trunk, 1 side (0.8%); c, double nerve trunks, 24 sides (20%); d, double nerve trunks, 4 sides
(3.3%); e, triple nerve trunks, 1 side (0.8%); f, quadruple nerve trunks, 1 side (0.8%). (Modified from Sun SQ, Dong JP. An applied anatomical study of the superior
laryngeal nerve loop. Surg Radiol Anat 1997;19:169-173; with permission.)
Fig. 1-69.
Variations of laryngeal nerves. Type I, V-shaped in 94 sides (78.3 ± 3.8%). Type II, U-shaped in 8 sides (6.7 ± 2.3%). Type III, Mixed in 14 sides (11.7 ± 2.9%).
Type IV, Juxtaposed-double in 1 side (0.8 ± 0.8%). Type V, Juxtaposed-triple in 1 side (0.8 ± 0.8%). SLN, superior laryngeal nerve; ILN, internal laryngeal nerve;
SCG, superior cervical ganglion; CT, communicating twig; ELN, external branch of laryngeal nerve; CTB, cricothyroid muscle branch; GB, thyroid branch. (Modified from
Sun SQ, Dong JP. An applied anatomical study of the superior laryngeal nerve loop. Surg Radiol Anat 1997;19:169-173; with permission.)
To prevent iatrogenic injury of the superior laryngeal nerve during surgical dissection near the thyroid apex in the neck, el-Guindy and Abdel-Aziz145
recommended anatomical localization of the nerve in the viscerovertebral angle, functional identification, and post-operative analysis.
INTERNAL LARYNGEAL NERVE
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INTERNAL LARYNGEAL NERVE
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The internal laryngeal branch pierces the thyrohyoid membrane with the superior laryngeal branch of the superior thyroid artery to enter and supply the
larynx. The internal branch is rarely identified by the surgeon; identification occurs only in those cases where a greatly enlarged upper pole of the thyroid
gland rises above the superior border of the thyroid cartilage (Fig. 1-70). The internal laryngeal nerve provides general sensory fibers to the larynx and the
area of the piriform recess of the laryngopharynx. It also provides parasympathetic fibers for the glandular elements and some taste fibers that supply taste
buds around the epiglottis.
Fig. 1-70.
Relationship between the (A) internal and (B) external branches of the superior laryngeal nerve with the superior thyroid artery and the upper pole of the thyroid
gland. (Modified from Droulias C, Tzinas S, Harlaftis N, Akin JT Jr, Gray SW, Skandalakis JE. The superior laryngeal nerve. Am Surg 1976;42:635-638; with permission.)
EXTERNAL LARYNGEAL NERVE
The external laryngeal branch, together with the superior thyroid vein and artery, passes under the sternothyroid muscles, posterior and medial to the
vessels. The nerve then passes beneath the lower border of the thyrohyoid muscle to continue inferiorly to innervate the cricothyroid muscle. In addition to
its contribution to phonation, the cricothyroid muscle plays a major role in the overall regulation of breathing by its control of expiratory resistance and
flow.146
An investigation by Wu et al.147 suggested that in some individuals a branch of the external laryngeal nerve may also contribute to the innervation of the
thyroarytenoid muscle and to the sensory supply of the vocal fold of the larynx. They postulated that the communicating branch of this nerve might
represent the nerve of the 5th embryonic branchial arch.
Cernea et al.148 stated that injury to the external branch of the superior laryngeal nerve will most likely endure, causing a permanent voice change for
professional vocalists. Fatigue, also, is common after injury to the external branch of the superior laryngeal nerve. Cernea et al. advised nerve identification
in the operating room, especially for patients with large goiters. The topographic anatomy and relations of the nerves and thyroid vessels are presented in
Figure 1-71. Cernea and colleagues have also presented further findings about the surgical anatomy of the superior laryngeal nerve.149,150
Fig. 1-71.
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Classification of the external branch of the superior laryngeal nerve, according to the potential risk of iatrogenic lesion during a hypothetical thyroidectomy. Type 1,
The nerve crosses the superior thyroid vessels 1 or more centimeters above a horizontal plane passing the upper border of the superior thyroid pole. Type 2a,
Nerve crossing the vessels less than 1 cm above the plane. Type 2b, Nerve crossing the vessel below the plane. (Modified from Cernea CR, Nishio S, Hojaij FC.
Identification of the external branch of the superior laryngeal nerve (EBSLN) in large goiters. Am J Otolaryngol 1995;16:307; with permission.)
In most patients, the blood vessels lie within the visceral compartment of the neck beneath the pretracheal fascia, while the external laryngeal nerve lies
between the fascia and the inferior pharyngeal constrictor muscle. There is thus a plane of dissection between the vessels and the nerve. In about 25
percent of individuals, the nerve lies beneath the fascia together with the vessels.151
HISTOLOGY
The thyroid gland is surrounded by the thyroid capsule, which is a thin layer of connective tissue. From the capsule, several septa extend within the thyroid
parenchyma, which is subdivided into several lobules. Epithelial cells (cuboidal or squamous) form the thyroid follicles; they are separated by thin connective
stroma which is rich in both lymphatic and blood vessels. Small bundles of nerves are present.
There is a colloidal gelatinous collection in the center of the follicle. Each follicle has two types of cells: follicular and parafollicular, or C cells.
According to Ross and Reith,152 the follicular cells are responsible for the following actions: synthesis of thyroglobulin, iodination, storage of thyroglobulin,
resorption of thyroglobulin, hydrolysis of thyroglobulin, and release of thyroid hormone into the blood and lymphatics.
The parafollicular, or C cells, can be found in the connective stroma between the follicles or in the follicular epithelium. Characteristically, they contain
several secretory granules.
PHYSIOLOGY
The follicular cells of the thyroid gland produce the thyroid hormones thyroxine (T 4) and triiodothyronine (T 3). The follicular cells trap and concentrate iodide
from that serum. The final product, thyroglobulin, accumulates within the colloid.
Figures 1-72 and 1-73 illustrate the synthesis of the hormones of the thyroid gland and their regulated secretion. Another function of the thyroid gland is the
secretion of thyrocalcitonin, which is the product of the parafollicular or C cells.
Fig. 1-72.
The synthesis and secretion of thyroxine (T4 ) and triiodothyronine (T3 ). TSH, thyroid-stimulating hormone; MIT, monoiodotyrosine; DIT, diiodotyrosine. (From Polk HC
Jr, Gardner B, Stone HH. Basic Surgery (5th ed). St. Louis: Quality Medical, 1995; with permission.)
Fig. 1-73.
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The physiologic regulation of thyroid hormone secretion and the thyroid tests which measure these parameters. TRH, thyrotropin-releasing hormone; TSH, thyroidstimulating hormone; TSI, thyroid-stimulating immunoglobulins; LATS, long-acting thyroid stimulator; TBG, thyroxine-binding globulin; FTI, free thyroxine index.
(Modified from Polk HC Jr, Gardner B, Stone HH. Basic Surgery (5th ed). St. Louis: Quality Medical, 1995; with permission.)
THYROID SURGERY
The surgical procedures for thyroid pathology are total bilateral lobectomy, total unilateral with partial contralateral lobectomy, and partial or subtotal
lobectomy (unilateral or bilateral). There is much controversy as to which is the most appropriate choice for each patient and each disease. The surgical
profession agrees to disagree about all these procedures.
Recently, minimally invasive thyroid surgery has been performed successfully. Ferzli et al.153 reported feasible and safe mini-thyroidectomy on glands no
larger than 7 cm.
We agree with the advice of Bliss and colleagues,154 "Minimally invasive thyroidectomy utilizing endoscopic techniques may also affect the practice of thyroid
surgery. Even so, understanding the surgical anatomy of the thyroid gland and its possible variations is paramount to safe and effective surgery."
We present the valuable flowchart of Johns155 for management of solitary thyroid nodules (Fig. 1-74). Delbridge et al.156 reported that the procedure of
choice for bilateral benign multinodular goiter is total thyroidectomy, since that procedure obviates recurrent goiter and a need for secondary thyroidectomy.
Fig. 1-74.
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Management flowchart for patient with solitary thyroid nodule. TSH, thyroid-stimulating hormone; FNA, fine-needle aspiration; RAD, radiation absorbed dose.
(Modified from Johns ME. The solitary thyroid nodule. Curr Ther Otolaryngol 1987;3:226-229; with permission.)
Read an Editorial Comment
Another surgical dilemma is the treatment of hyperparathyroidism, which is considered in the following section on the parathyroid gland.
According to Cooper,157 treatment of hyperthyroidism is still somewhat controversial. American endocrinologists advise antithyroid drugs for young individuals,
but iodine 131 for adults. European and Japanese endocrinologists are more likely to recommend antithyroid drugs regardless of the patient's age. All over the
world, surgery is used infrequently.
Ron et al.158 reported that iodine 131 appears to be safe treatment for hyperthyroidism without significantly increasing the risk of total cancer mortality.
In a study of 124 cases of malignant tumors of the thyroid, Skandalakis et al.159 found papillary carcinoma to be the largest group, accounting for 39.5%
They reported that this type of tumor is the least malignant.
In papillary carcinoma of the thyroid, Noguchi et al.160 stated that microscopic involvement of the cervical lymph nodes is 80%. Mirallié et al.161 presented
tables showing localization of lesion in papillary thyroid carcinoma (Tables 1-7, 1-8). Clark,162 in his invited commentary, made the following
recommendations: (1) The surgeon should look for nodes in the central neck; if present, they should be removed; (2) Therapeutic functional modified radical
neck dissection should be performed, with preservation of motor nerves in toto; (3) Prophylactic neck dissection should not be performed, since proportionally
few patients treated with irradiation develop nodal recurrence of metastases; (4) "Berry picking" is useless, since with palpable metastatic lymph nodes,
smaller nodes also have micrometastases.
Table 1-7. Localization of Node Involvement
No. in Node-Positive Patients
Node Localization Ipsilateral (n=71) Contralateral (n=30)
Paratracheal
60 (83.3%)
25 (34.7%)
Midjugular
44 (61.1%)
12 (16.7%)
Supraclavicular
26 (36.1%)
5 (6.9%)
Subdigastric
20 (27.8%)
2 (2.8%)
Source: Mirallié E, Visset J, Sagan C, Hamy A, Le Bodic MF, Paineau J. Localization of cervical node metastasis of papillary thyroid carcinoma. World J Surg 1999;23:970974; with permission.
Table 1-8. Node Involvement According to Localization of the Tumor in the Thyroid Lobe
No. by Site in Thyroid Lobe
Node
Upper Third Middle Third Lower Third Diffuse Unknown Isthmic
Ipsi paratracheal
9
6
10
18
14
3
Ipsi jugular
6
5
6
15
11
1
Ipsi supraclav
3
3
2
13
5
0
Ipsi subdig
7
1
1
5
5
1
Contralat paratrach 2
4
1
10
8
0
Contralat jugular
1
2
0
7
2
0
Contralat supraclav 0
2
1
2
0
0
Contralat subdig
0
0
1
1
0
0
Ipsi paratracheal: ipsilateral paratracheal nodes; Ipsi jugular: ipsilateral jugular nodes; Ipsi supraclav: ipsilateral supraclavicular nodes; Ipsi subdig: ispilateral
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Ipsi paratracheal: ipsilateral paratracheal nodes; Ipsi jugular: ipsilateral jugular nodes; Ipsi supraclav: ipsilateral supraclavicular nodes; Ipsi subdig: ispilateral
subdigastric nodes; Contralat paratrach: contralateral paratracheal nodes; Contralat jugular: contralateral jugular nodes; Contralat supraclav: contralateral
supraclavicular nodes; Contralat subdig: contralateral subdigastric nodes.
Source: Mirallié E, Visset J, Sagan C, Hamy A, Le Bodic MF, Paineau J. Localization of cervical node metastasis of papillary thyroid carcinoma. World J Surg 1999;23: 970974; with permission.
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Chen et al.163 reported that although rare, isolated metastatic disease to the thyroid gland from nonthyroid primary tumors have been observed, including
the following:
Renal cell carcinoma
5 cases
Esophageal adenocarcinoma
1 case
Pulmonary squamous cell carcinoma 1 case
Gastric leiomyosarcoma
1 case
Lingual squamous cell carcinoma
1 case
Parotid gland carcinoma
1 case
Boyd et al.164 recommend preoperative fine-needle aspiration of thyroid tumor as a powerful diagnostic tool for thyroid cancer. Tarantino et al.165 stated
that the role of fine-needle aspiration biopsy as well as flow cytometry for the evaluation of neck adenopathy has not been defined, but aspiration is reliable
for diagnosis of metastatic disease.
Matsuzuka et al.166 reported that the rare thyroid lymphoma may be detected by the Southern blot (IgH-JH or IgL-JÎ probes) in approximately 85% of the
cases.
Smith et al.167 described primary Hodgkin's disease of the thyroid gland and they found 19 similar cases in the literature.
Hermann et al.168 advised reoperation in recurrent hyperthyroidism, in the absence of contraindications, since this procedure is safe and effective.
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Lo et al.169 reported the following: "Patients with anaplastic carcinoma of thyroid have a dismal prognosis heralding imminent death. Surgical ablation followed
by adjuvant therapy can provide palliation for selected patients only." The senior author of this chapter (JES) had only one such case and despite the fact
that he cauterized and removed protruding anaplastic thyroid tissue daily and performed a tracheostomy, and despite irradiation, the patient died a few
months after surgery.
Dhar et al.170 reported that tumor microvascular densities perhaps is a new prognostic indicator for differentiated thyroid carcinoma. Dhar et al. indicated
that patients with thyroid carcinoma who have dThdPase expression and high tumor vascularity probably will need adjuvant radiotherapy.
Sanders and Silverman171 stated that follicular and Hürthle cell carcinoma of the thyroid gland with minimal capsular invasion behave in a benign way, and
both these types have a similar prognosis.
Gauger et al.172 stated as follows: "[T]he size of a follicular lesion cannot be used to predict a final diagnosis of follicular carcinoma and is of no value when
making intraoperative decisions about the extent of thyroid resection."
Invasion of the cervicovisceral axis (larynx, trachea, and esophagus) by thyroid carcinoma is a rare occurrence. According to Machens et al.,173 neoplastic
spread in this area is more often caused by extrathyroidal growth than by nodal metastasis. They recommend paratracheal and paraesophageal lymph node
clearance at primary operation.
In a study of patients who had undergone primary and reoperative surgery for sporadic medullary thyroid carcinoma, Gimm et al.174 advised transsternal
mediastinal lymph node dissection for those with lymph node metastases.
Hay et al.175 stated that bilateral thyroid lobectomy (BTL) for thyroid papillary carcinoma is the preferred initial surgical procedure over unilateral lobectomy
(UL) since the rates for local recurrence and nodal metastasis with UL are 14% and 19%, respectively, compared to 2% and 6% with BTL.
Hereditary medullary thyroid carcinoma should be treated with prophylactic total thyroidectomy during childhood; if calcitonin levels are elevated or if children
are older than 10 years, lymphadenectomy should be included according to Dralle et al.176
We quote from Kebebew et al.177 on reoperation of residual medullary thyroid carcinoma (MTC):
Although reoperation in patients with residual MTC rarely results in biochemical cure, cervical reexploration is safe and in selected patients may limit
MTC progression. Lateral cervical node dissection could be beneficial at the time of initial surgical treatment because of the high frequency of residual
MTC in the lateral cervical nodes. Noninvasive imaging studies were helpful but far from perfect for guiding the reexploration for locoregional residual
MTC.
Discussion of this paper included comments on lateral aberrant thyroid tissue, benign metastasizing goiter, and lateral anlages; monitoring of serum calcitonin
and CEA levels; and the importance of early operation for cure. We urge the interested reader to study this article in its entirety.
While Voutilainen et al.178 stated that there is currently no curative therapy for patients with anaplastic thyroid carcinoma, Nilsson et al.179 suggested that
a combination of preoperative hyperfractionated accelerated radiotherapy, doxorubicin pre- and postoperatively, and debulking surgery (when possible) may
produce better local control and, possibly, also increased survival rate.
For the management of amiodarone-associated thyrotoxicosis, a study by Hamoir et al.180 suggested that thyroidectomy is more effective than conventional
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medical treatment.
Chao et al.181 reported that most of the patients with thyroid carcinoma and concurrent hyperthyroidism have small carcinomas.
Shimizu et al.182 reported endoscopic resection of thyroid tumors in 5 patients.
For well-differentiated thyroid carcinomas invading the trachea, Yang et al.183 recommend surgical resection followed by primary reconstruction.
ANATOMIC COMPLICATIONS OF THYROIDECTOMY
Vascular Injury
Thyroid arteries must be ligated carefully; the superior thyroid artery tends to retract, thus filling the field with blood.
The superior thyroid artery should not be clamped above the upper pole of the thyroid because the external laryngeal nerve may be injured. If the artery is
clamped at the pole, a branch may escape, with resulting hemorrhage. The superior pole, together with the artery, should be clamped and ligated (Fig. 1-75).
Fig. 1-75.
The superior thyroid vessels should be clamped and divided within the substance of the upper pole of the thyroid gland. Failure to secure these vessels adequately
will result in massive hemorrhage. (Modified from Akin JT Jr, Skandalakis JE. Technique of total thyroid lobectomy. Am Surg 1976;42:648-656; with permission.)
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Separation of the inferior thyroid artery from the recurrent laryngeal nerve requires care. Where the nerve passes between branches of the artery, the
individual branches must be ligated and divided separately. Retraction of the artery can result in a hasty attempt at hemostasis that will injure the recurrent
nerve.
Avisse et al.131 reviewed 17 cases of right nonrecurrent inferior laryngeal nerve. An aberrant right subclavian artery was present in 2 cases. From their cases
and from a review of the literature the authors conclude that this arterial anomaly is always present with right nonrecurrent inferior laryngeal nerve. The
authors review the anatomic and embryologic bases and discuss the diagnostic and therapeutic implications of this double anomaly.
The middle thyroid vein is short and easily torn. If it is divided accidentally, it will retract, making hemostasis difficult. With too much traction of the thyroid
gland, the vein becomes flattened and bloodless, making it unrecognizable until it is severed. The tear is often at the junction of the middle thyroid vein and
jugular vein, presenting the danger of an air embolism. Such an injury to the vein requires immediate repair.
Bleeding during thyroglossal duct cyst surgery, pyramidal lobe excision, or division of a thick thyroid isthmus during thyroid surgery or tracheostomy is most
likely due to injury of the cricothyroid artery. This artery springs from the superior thyroid artery or from its anterior branch. It follows the upper border of the
cricothyroid muscle and membrane (Fig. 1-76).
Fig. 1-76.
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Nerves and arteries of the larynx, lateral view.
The thoracic duct is rarely injured in thyroidectomy, although injury during radical neck dissection is not unknown. The duct can be ligated with impunity.
Organ Injury
The pleura is rarely injured, but we have records of two patients in whom pneumothorax occurred. In one, a huge toxic goiter extended far laterally; in the
other, the thyroid was retrosternal.
Both anteriorly and posteriorly the two pleurae approach the midline, and hence each other. Intrathoracic goiter can descend into the anterior or posterior
mediastinum, bringing the thyroid gland close to the pleura (Fig. 1-77).
Fig. 1-77.
An enlarged, retrosternal thyroid gland showing its relation to the pleura (dotted line). (Modified from Harlaftis N, Tzinas S, Droulias C, Akin JT Jr, Gray SW,
Skandalakis JE. Rare complications of thyroid surgery. Am Surg 1976;42:645-647; with permission.)
Pandya and Sanders184 described a method whereby a Foley catheter was placed beyond the substernal component of the goiter. The catheter and its
inflated balloon were carefully tractioned upward, delivering the substernal goiter in the neck. This procedure was used safely and successfully on two
patients, thereby preventing the need for a sternotomy. Though the reported use of this procedure is very limited, perhaps the procedure is sound.
The trachea and esophagus can be injured in the presence of thyroiditis, calcified adenoma, or malignancy. The true capsule of the thyroid, the pretracheal
fascia, the trachea, and the esophagus can be so fixed to one another that vigorous attempts at separation may perforate the trachea. A tracheal
perforation may require immediate tracheostomy.
The parathyroid glands are close to the posterior thyroid capsule. With total conservative thyroidectomy, hypocalcemia occurs in 20 to 25 percent of
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The parathyroid glands are close to the posterior thyroid capsule. With total conservative thyroidectomy, hypocalcemia occurs in 20 to 25 percent of
patients.185,186 In most of these the drop in calcium (perhaps owing to trauma to the glands) is small and transitory; it persists in 1-4 percent of cases. In
radical thyroidectomy, the incidence is higher. Preservation of only one parathyroid gland will avoid the symptoms of hypoparathyroidism.
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Nerve Injury
Vagus Nerve
Fernando and Lord187 presented data to indicate that inadvertent interruption of the vascular supply of the vagus nerve could be the hitherto unsuspected
cause of several neurologic problems following thyroidectomy, carotid endarterectomy, and surgery for correction of aortic arch aneurysms. It is possible that
some postoperative neurologic problems attributed to accidental injury of the recurrent laryngeal nerve might have actually resulted from ischemia or edema
of the vagus nerve, with similar results (Figs. 1-78, 1-79, 1-80, and 1-81).
Fig. 1-78.
Dissection of the right side of the human neck. The large vagal artery (A) receives reinforcing branches (R) from the common (B) and internal (I) carotid arteries.
Inadvertent damage to these vessels in carotid endarterectomy may account for injury to the vagus nerve (N) and subsequent vagal palsy. (Modified from Fernando
DA, Lord RSA. The blood supply of the vagus nerve in the human: its implication in carotid endarterectomy, thyroidectomy and carotid arch aneurectomy. Ann Anat
1994;176:333; with permission.)
Fig. 1-79.
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Neck dissection of the human. A large vagal vein (V) drains venous blood to the superior (S) and inferior (I) thyroid veins. Interruption to these vessels in
thyroidectomy may account for vagal damage leading to voice changes. The vagus nerve is indicated by N. (Modified from Fernando DA, Lord RSA. The blood supply of
the vagus nerve in the human: its implication in carotid endarterectomy, thyroidectomy and carotid arch aneurectomy. Ann Anat 1994;176:333; with permission.)
Fig. 1-80.
Neck dissection of the human. The prominent vagal vein (V) drains into the inferior thyroid vein. The vagal artery arising from the inferior thyroid artery lies alongside
the vein. Sutures placed distal to the point of opening of the vagal vein or the commencement of the vagal artery may result in degenerative changes or edema of
the vagus with consequent vagal palsy. The vagus nerve is indicated by N. (From Fernando DA, Lord RSA. The blood supply of the vagus nerve in the human: its
implication in carotid endarterectomy, thyroidectomy and carotid arch aneurectomy. Ann Anat 1994;176: 333; with permission.)
Fig. 1-81.
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Dissection of the left side of the neck and thorax. The large vagal artery (A) arises from the inferior thyroid artery. This vessel bifurcates into ascending and
descending branches. The descending branch receives reinforcing twigs from the aorta, bronchial, and esophageal arteries. Damage to these small vessels in
thyroidectomies and removal of aneurysms of the aortic arch may also contribute to vagal damage and consequent symptoms of vagal palsy and voice changes. The
vagus nerve is indicated by N; common carotid artery by B. (Modified from Fernando DA, Lord RSA. The blood supply of the vagus nerve in the human: its implication
in carotid endarterectomy, thyroidectomy and carotid arch aneurectomy. Ann Anat 1994;176:333; with permission.)
According to the same authors, the cervical and thoracic parts of the vagus have a single large vagal artery, most commonly on the anteromedial side of the
nerve, which is formed by contributions at several levels. Superiorly, the vagus receives a branch from the posterior inferior cerebellar artery. Inferiorly, it is
supplied by a branch from the inferior thyroid artery (the main trunk of the vagal artery). In between, the vagus receives reinforcing twigs directly from the
common carotid and internal carotid arteries at 1.5 cm intervals. The vagal veins drain into the superior and inferior thyroid veins. Vagal palsy follows
approximately 27% of carotid endarterectomies. The type of damage to the vagus nerve is comparable to that of the spinal cord with interruption of radicular
branches.
Fernando and Lord187 also wrote that ligating the inferior thyroid artery close to its origin will interrupt the principal supply to the vagus (which typically
arises 2-3 cm from the inferior thyroid's origin). Ligation of the venous drainage of the nerve results in edematous changes and nerve palsy.
Recurrent Laryngeal Nerve
In a series of thyroid operations in which 217 recurrent laryngeal nerves were involved, Holt and coworkers188 found 9 nerve injuries, of which 4 were
permanent. In the same series there were three injuries to superior laryngeal nerves; one was permanent.
Most recurrent laryngeal nerve injuries occur "just below that point where the nerve passes under the lower fibers of the inferior constrictor muscle to
become intralaryngeal."189 The usual cause is a hemostatic stitch.137 Another source of injury is mass ligation of the vessels of the lower pole of the thyroid.
Such ligation may include a recurrent nerve more anterior than usual. The nerve should be identified before ligating the inferior thyroid vein. The specific
causes of recurrent laryngeal nerve injury have been evaluated by Chang-Chien190 (Table 1-9).
Table 1-9. Recurrent Laryngeal Nerve Vulnerability
Cause of Vulnerability
Percent Encountered
Lateral and anterior location
1.5-3.0
Tunnelling through thyroid tissue
2.5-15.0
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Tunnelling through thyroid tissue
2.5-15.0
Fascial fixation
2.0-3.0
Arterial fixation
5.0-12.5
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Close proximity to inferior thyroid vein 1.5-2.0+
Data from six series of Chang-Chien Y. Surgical anatomy and vulnerability of the recurrent laryngeal nerve. Int Surg 65:23, 1980.
Source: Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.
The results of injury to the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve have been outlined by Esmeraldo and
coworkers.191
In unilateral recurrent nerve injury, the affected vocal cord is paramedian in position due to tension on the vocal ligament by the cricothyroid muscle. Voice is
preserved (not unchanged).
With unilateral injury to both the recurrent laryngeal and superior laryngeal nerve the affected cord is in an intermediate position, resulting in hoarseness and
inability to cough. The affected cord will move toward the midline with time. Voice improves, but is followed by narrowing of the airway. Loss of the superior laryngeal
nerve leaves the tissues of the larynx and piriform recesses insensate, resulting in loss of the cough reflex and difficulties with aspiration and clearing the airway.
With bilateral recurrent nerve injury, because of the narrowing of the airway produced by unopposed cricothyroid muscles, tracheostomy becomes necessary.
Scanlon and colleagues186 reported a series in which 6 of 245 patients who had undergone total thyroidectomy experienced recurrent laryngeal nerve
paralysis. All but one recovered within a year.
Postoperative hoarseness is not always the result of operative injury to laryngeal nerves. From 1 to 2 percent of patients have a paralyzed vocal cord prior
to thyroid operation.188 Neel and coworkers at the Mayo Clinic 192 examined 202 cases of vocal cord paralysis, of which 153 (76 percent) followed
thyroidectomy, 36 (18 percent) were of various known etiologies, and 13 (6 percent) were of idiopathic origin. We strongly advise the general surgeon to
have an indirect laryngoscopy performed prior to thyroidectomy.
Miyauchi et al.133 performed ansa cervicalis-recurrent laryngeal nerve anastomosis in the neck for vocal cord paralysis due to mediastinal lesions. They
reported excellent improvement in phonation without vocal cord movement.
We believe that the patient should be told that in spite of all precautions, there is a possibility that there may be some vocal disability following
thyroidectomy. Dysphagia can result from damage to early rising branches of the recurrent laryngeal nerves that supply the esophagus.193
Superior Laryngeal Nerve
Lekacos et al.194 noted 3 cases of superior laryngeal nerve injury after 54 classical high ligations of the superior thyroid artery. They observed that patients
with loss of the external laryngeal nerve complained of voice instability, quick vocal fatigue and inability to produce high-pitched sounds, with difficulty in
singing. No injuries were recorded in 227 other cases in which the branches of the superior thyroid artery were ligated at the superior pole. According to
Durham and Harrison,195 the external laryngeal nerve closely parallels the superior thyroid vessels in about 20% of cases, and even passes between the
branches of the superior thyroid artery near the superior pole in 6-14% of cases.
In their excellent monograph, Johns and Rood196 discussed classification of the paralyzed vocal cord. The paralyzed vocal cord may be paramedian
(interruption of the recurrent laryngeal nerve alone [Wagner-Grossmann theory]) or intermediate (interruption of the recurrent and superior laryngeal nerves).
Injury to the superior laryngeal nerve alone can be identified by rotation of the superior glottis to the affected side, and by bowing of the vocal cord.
We agree with the statement of Johns and Rood:
. . .A thorough understanding of the anatomy of the larynx and the relationships of the laryngeal nerve supply to the intrinsic muscles of the larynx is a
prerequisite to adequate localization of the site of lesion in laryngeal nerve injury. Successful management of the patient is based upon an accurate
etiologic diagnosis.196
Cervical Sympathetic Chain
A sympathetic ganglion can be confused with a lymph node and can be removed when the surgeon operates for metastatic papillary carcinoma of the thyroid.
In one of our patients, inferior cervical and first thoracic ganglia were fused to form a nodelike structure that was removed.197 The surgeon must identify any
apparent lymph node related to the vertebral artery and fixed in front of the transverse process of the 7th cervical vertebra.
Injury to the cervical sympathetic nerve results in Horner's syndrome: (1) constriction of the pupil, (2) partial ptosis of the upper eyelid, (3) apparent
enophthalmos, (4) dilatation of the retinal vessels, and (5) flushing and drying of the facial skin on the affected side.
Thyroidectomy of large goiters will be facilitated by division (high, middle or low) of the infrahyoid muscles. The expectation is that injury to the ansa
cervicalis will thus be avoided. High division was recommended by Farquharson and Rintoul198 and Paparella and Shumrick,199 middle division by Wilson,200
and low division by Stell and Maran.201
The formation and location of the ansa cervicalis is variable. We have seen a singular root in one case, which is a rare phenomenon. In most cases, there are
two roots which unite; segmental branches spring from this union. The pathway of these branches is quite variable; therefore there is no "typical" segmental
innervation of the infrahyoid muscles. The sternohyoid and sternothyroid muscles are innervated by branches that spring after the union of the upper
descendent root (C1) and the lower descendent root (C2, C3) of the ansa cervicalis (Fig. 1-82). The entrance of the motor branch of these two muscles is
characteristically in the vicinity of the thyroid cartilage, and just above the jugular notch, or, rather, bisecting the angle between the inferior segment of the
sternohyoid muscle and the clavicle.
Fig. 1-82.
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A plan of the right hypoglossal nerve and ansa cervicalis.
For all practical purposes we do not know the topography of the union and the pathway of the branches of the ansa cervicalis in a given patient. Therefore,
we must prepare carefully for facilitating thyroidectomy by unilateral or bilateral division of the four infrahyoid or strap muscles which are innervated by the
ventral rami of C1, C2 and C3 via the hypoglossal nerve (Fig. 1-83). The muscles should ordinarily be divided high to protect their nerve supply. By all means
we agree with Beahrs et al.23 that the integrity of these four muscles should be preserved.
Fig. 1-83.
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The ansa cervicalis, its roots, and its branches to the infrahyoid muscles.
In our practices we occasionally divide the muscles; the point of division varies depending on the size of the megathyroid. While our postoperative
observations might have been superficial, we never noticed any changes in voice, deglutition, or mastication. When these four muscles are paralyzed, the
hyoid bone and laryngeal apparatus malfunction and impair swallowing.
We strongly advise the interested student to carefully read the papers of Yerzingatsian.202,203
Chao et al.204 reported that the uncommon procedure of reoperative thyroid surgery can be safely performed with little morbidity to the patient.
Postoperative complications were as follows:
Transient hypoparathyroidism
5.2%
Permanent hypoparathyroidism
1.7%
Transient recurrent laryngeal nerve palsy
2.6%
Permanent recurrent laryngeal nerve palsy 1.7%
We quote from Profanter et al.205 on primary hyperparathyroidism (HPTH):
Sonography had an overall accuracy to correctly localize enlarged parathyroid glands of 80%, and scintiscanning had overall accuracy of 78.6%. The
accuracy of localization was increased up to 84.6% if both diagnostic procedures were applied. In patients with normal thyroid residues the accuracy
of sonography was 85.7%, and it was 100% if scintiscanning was used. . . Preoperative localization techniques in patients with primary HPTH and
previous thyroid surgery have high accuracy. This allows for an imaging- directed operative strategy, thus preventing unnecessary bilateral neck
explorations, which carry a high risk of recurrent laryngeal nerve injury.
We quote from Menegaux et al. about secondary thyroidectomy:206
The permanent complication rate is higher in thyroid reoperations than in primary thyroid operations. However, we believe that this 2% rate is low
enough to allow reoperation whenever it is necessary, provided precise operative rules are respected.
PARATHYROID GLANDS
EMBRYOGENESIS
Normal Development
In the fifth and sixth weeks of gestation the embryonic pharynx is marked externally by four branchial clefts of ectoderm. Internally there are five branchial
pouches of endoderm. These clefts and pouches, together with the branchial arches between, compose the branchial apparatus. Although transitory, the
apparatus leaves some normal derivatives: the thyroid and parathyroid glands, thymus, ultimobranchial body, eustachian tube, middle ear, and external
auditory canal. There is also the possibility that some normally transient structures will persist into adulthood.
The parathyroid glands develop as epithelial thickenings of the dorsal endoderm of the third and fourth branchial pouches. As a result of their subsequent
migration, the derivatives of the third pouch become the inferior parathyroids (parathyroids III), while those of the fourth pouch become the superior
parathyroids (parathyroids IV) (Fig. 1-84). Both primordia descend from their level of origin, but parathyroids III are closely associated with the thymus gland
derived from the ventral portion of the third pouch. This association usually ends in the eighth week, leaving the parathyroid gland near the level of the lower
border of the thyroid gland. Occasionally, parathyroids III become encapsulated with the thymus and may be carried into the mediastinum. This is of no
significance to the patient, but it may be frustrating for the surgeon.
Fig. 1-84.
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The migratory pathways of the parathyroid glands. The glands may be found at any point along those pathways, usually at the levels indicated by the horizontal
arrows. (Modified from Gray SW, Skandalakis JE, Akin JT Jr. Embryological considerations of thyroid surgery: Developmental anatomy of the thyroid, parathyroid, and
the recurrent laryngeal nerve. Am Surg 1976;42:621-628; with permission.)
The following points are important to consider:
Is the genesis of the parathyroid glands of ectodermal origin, and therefore from pharyngeal clefts 3 and 4? Maybe.
Do the parathyroid glands arise from the neural crest, meaning they belong to the APUD system? Maybe.
Lundgren et al.207 demonstrated that the abnormal parathyroid tissue of normocalcemic primary hyperparathyroidism is characterized by morphologic and functional
derangements. These are consistently seen in patients with primary hyperparathyroidism and hypercalcemia.
Congenital Anomalies
Abnormal parathyroid development includes variations in location, number, shape, size, weight, and color. Parathyroid cysts may be congenital. The LobdellDiGeorge syndrome (agenesis of the parathyroid and thymus) is an anomaly which involves the caudad branchial arches and pouches, and presents with
approximately 38 combinations.
Figure 1-85 illustrates the anatomic locations of ectopic parathyroid glands found in a study by Shen et al.208 The procedure for locating such glands is
presented in "Strategy for Finding Parathyroid Glands" later in this chapter. Casas et al.,209 Malhotra et al.,210 and Martin et al.211 advised preoperative
parathyroid localization with technetium-99m-sestamibi scan. This not only may reduce operative time, but also may contribute to successful surgery.
Fig. 1-85.
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Anatomic locations of ectopic parathyroid glands, with number found in each location (n=54). (Modified from Shen W, Düren M, Morita E, Higgins C, Duh QY, Siperstein
AE, Clark OH. Reoperation for persistent or recurrent primary hyperparathyroidism. Arch Surg 131:861-869; with permission.)
SURGICAL ANATOMY
General Topographic Anatomy
The parathyroid glands are usually found on the posterior surface of the thyroid gland, each with its own capsule of connective tissue. They are occasionally
included in the thyroid capsule, or one of them may even follow a blood vessel deep into a sulcus of the thyroid.
The frequency of such occult glands is not known. Farr and associates212 found 10 examples among 100 patients with parathyroid tumors. Few intrathyroid
parathyroid glands are discovered in the absence of disease. Several techniques have been developed for locating occult parathyroid glands.213,214
McIntyre et al.215 reported that 18 of 309 patients (6%) who had undergone parathyroidectomy had intrathyroidal parathyroid glands. Libutti et al.216
reported an intrathyroidal parathyroid gland in 7 percent of the cases and they advise ultrasonography for selection of patients for thyroid resection.
Gray et al.217 tabulated the adult position of 200 parathyroid glands in 50 cadavers. Table 1-10 shows the location of these glands, all of which could be
considered "normal."
Table 1-10. Location of Parathyroids in 50 Cadavers
Location on Thyroid Gland
Superior Parathyroids, % Inferior Parathyroids, %
Upper third
8
2
Middle third
80
12
Lower third or below inferior pole 12
86
100
100
Source: Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.
Extreme locations are very rare, although glands have been found as high as the bifurcation of the carotid artery and as low as the mediastinum.139 In
practice, the surgeon should start at the point at which the inferior thyroid artery enters the thyroid gland. The superior parathyroid glands will probably lie
about one inch above it, and the inferior parathyroid glands will probably lie one-half inch below it. If the inferior gland is not found, it is more likely to be
lower than higher.
Typically there are four parathyroid glands, but it is fairly common to have more or fewer. When fewer than four glands are found, the possibility of ectopic
glands is hard to rule out. Two parathyroid glands can be fused to one another; such a pair can be differentiated from a bilobate gland by the presence of a
cleavage plane between them.139
Hooghe et al.218 reported that in 416 parathyroidectomies, 19% of the organs were found in ectopic locations, such as distant to the thyroid lobes, along
the esophagus, or in the upper anterior mediastinum within thymic remnants. Among Hooghe's patients, 5% had supernumerary parathyroids. Parathyroid
tissue within the thymus with primary hyperthyroidism was reported by Wei et al.219
McHenry et al.220 studied parathyroid localization with technetium-99m-sestamibi, and reported that the sensitivity and positive predictive value of this
scintigraphic technique is comparable to or better than other localization procedures. The same authors reported that the test's lack of sensitivity for the
detection of multiglandular disease precludes its use for bilateral routine exploration in patients with hyperparathyroidism.
Although CT, MRI, and technetium-99m/thallium-201 have been used for identifying the glands' primary hyperparathyroidism, the search continues for better
imaging modalities. Bonjer et al.221 explored the possibility of using 2-methoxyisobutylisonitrile (MIBI) labeled with technetium-99m scanning as a preoperative
and intraoperative technique using a hand-held gamma probe. Despite the fact that Bonjer and colleagues concluded that the MIBI probe did not improve the
outcome of parathyroid surgery in their study, we agree with the invited commentary of Linos221 that there is room for improvement of this technique and
that the probe should continue to be used. Indeed, Purcell et al.222 have reported a high degree of success using a combination of high-resolution ultrasound
and technetium Tc99 sestamibi scanning to locate the parathyroids before surgery in patients with hyperparathyroidism.
Read an Editorial Comment
Szabo et al.223 found in a retrospective study of 659 patients with sporadic primary hyperparathyroidism that the incidence of parathyrodid adenoma in two
enlarged parathyroid glands was approximately 12%.
Read an Editorial Comment
Pre-operative localization of parathyroid adenomas is even more difficult when thyroid nodules are present. Krausz et al.224 advise that in the absence of
thyroid pathology, high-resolution ultrasonography should be the first step for localization of a parathyroid adenoma prior to surgery. They reported that in
patients with primary hyperparathyroidism alone, scintigraphy with technetium-99m-sestamibi is an effective diagnostic tool. Scintigraphy and
ultrasonography are needed when the patient has thyroid abnormalities in addition to hyperparathyroidism.
Vascular Supply
Alveryd225 studied parathyroid arterial supply in 354 autopsy specimens. It was observed that both the superior and inferior parathyroids are usually supplied
by the inferior thyroid artery: 86.1% on the right side, 76.8% on the left. In the absence of an inferior thyroid artery, both the superior and inferior
parathyroid glands were supplied by the superior thyroid artery in the majority of cases225 (Fig. 1-86, Table 1-11). After a study of 160 autopsy specimens,
Wang139 stated that the vascular pedicle could be used to locate a low-lying parathyroid IV (Fig. 1-87).
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Wang
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stated that the vascular pedicle could be used to locate a low-lying parathyroid IV (Fig. 1-87).
Table 1-11. Variations in Vascular Supply of 1405 Parathyroids Identified at 354 Autopsiesa,b
Right Side
Left Side
1 Parathyroid 2-3 Parathyroids Total 1 Parathyroid 2-3 Parathyroids Total
Inferior thyroid artery
12.4 c
86.4
98.8
20.1 c
76.8
96.9
Superior thyroid artery
8.7
0.6
9.3
15.0
2.8
17.8
Thyroid ima artery
0.6
0.6
0.6
0.6
Artery from larynx, trachea, esophagus, or mediastinum 1.7
1.7
2.0
2.0
a From
b
Alveryd A. Parathyroid gland in thyroid surgery. Acta Chir Scand 1968;389 (suppl):1-120.
The figures indicate the frequency in percent of total number of cases.
cIncludes
10 cases (right side) and 13 cases (left side) in which only one gland was identified.
Source: Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.
Fig. 1-86.
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A, Schematic drawings showing the positions of the parathyroid glands and their vascular supply in 12 cases with 5 parathyroids without adenoma. The right and
left parathyroids are indicated separately in each case. B, Variations in the location of the parathyroid glands in relation to the inferior artery on both sides in 354
cases with 2-5 glands. The schematic drawings show a lateral view of the larynx and trachea with the thyroid mobilized and dislocated ventrally and medially. Dotted
horizontal lines indicate the levels of the entrance of the uppermost and lowermost branches of the inferior artery in the thyroid parenchyma. The hatched areas
indicate the location of the parathyroids. For the sake of completeness, the cases without an inferior thyroid artery are also registered in separate drawings, but in
these the location of the parathyroid is not shown. (Modified from Alveryd A. Parathyroid gland in thyroid surgery. Acta Chir Scand (suppl) 1968;389:1-120; with
permission.)
Fig. 1-87.
A. A to C. Anatomic distribution of 312 upper parathyroid glands (parathyroid IV). B. A to D. Anatomic distribution of 312 lower parathyroid glands (parathyroid III).
(Modified from Wang C. The anatomic basis of parathyroid surgery. Ann Surg 1976;183:271; with permission.)
As noted previously, Nobori et al.109 found that a branch from the superior thyroid artery that anastomosed with the inferior thyroid artery supplied the
superior parathyroid gland in approximately 45% of cases. The greater frequency of supply by the superior thyroid artery seen in the work of Nobori et al. in
contrast to that of others could be attributable to the techniques used or perhaps to genetic differences in anatomy.
Delattre et al.226 found that the blood supply to the parathyroids seems to originate as follows:
Superior parathyroids:
77.1% - Inferior thyroid artery
15.3% - Anastomosis of inferior and superior thyroid arteries
Inferior parathyroids:
90.3% - Inferior thyroid artery
Ander et al.227 studied the blood supply and parathyroid hormone secretion in patients with parathyroid adenoma or secondary hyperplasia. They reported
that, despite devascularization, increased parathyroid hormone secretion remained unchanged.
Innervation
The innervation of the parathyroid glands is either direct from the superior or middle cervical ganglia, or through a plexus in the fascia on the posterior lobar
aspects.
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aspects.
HISTOLOGY AND PHYSIOLOGY
The major portion of the parathyroid parenchyma is formed by the principal cells and a minor part is formed by oxyphilic cells. Perhaps all the parathyroid cells
participate in the secretion of the parathyroid hormone, parathormone (PTH), and in the regulation of calcium and phosphate metabolism. We strongly advise
the interested student of the parathyroids to read the excellent paper of Weber et al.,228 which suggests that the PTH content of parathyroid tissue may be
of use in differentiating normal from abnormal organs.
To maintain normal calcium in the blood, a feedback system is formed between the circulating calcium and the secretion of PTH. Too much serum calcium
inhibits production of PTH; too little stimulates secretion.
Cisneros et al.229 stated that in patients with nonmetastatic squamous cell carcinoma of the skin, humoral hypercalcemia of malignancy (tumor hormone
secretion into the systemic circulation distant to the skeleton with subsequent bone resorption) can be produced by parathyroid hormone-related protein
(PTHrP).
We quote from Perez and Pazianos230:
[T]he absence of an elevated PTH level in the presence of hypercalcemia should exclude primary hyperparathyroidism as the cause. Rarely....the PTH
level, although in the normal range, is considered too high for nonparathyroid hormone-mediated cause of hypercalcemia other than primary
hyperparathyroidism. To the best of our knowledge, the mediator involved in the parathyroid glands of these subjects is unknown.
However, we agree with LiVolsi231 who stated that "our understanding of parathyroid pathophysiology is far from complete. As suggested by the authors of
this study, information from molecular biology studies of calcium-sensing receptors and the genes regulating calcium sensitivity in parathyroid tissue (both
normal and abnormal), remains to be defined."
SURGERY OF THE PARATHYROIDS
The most common indication for parathyroid surgery is hyperparathyroidism. Very rarely parathyroid cysts are associated with hyperparathyroidism, but these
cysts have never been found to be malignant.
A case of a functioning parathyroid cyst was presented by Safran;232 this review stated that Mitmaker reported only 162 cases of parathyroid cysts in the
literature in 1991, with a lower incidence of functioning cysts. Safran recommended aspiration of these cysts, which present as masses at the lateral or lower
neck. Hypercalcemia, hypophosphatemia, and elevated serum parathormone are always present, but disappear after the removal of the cyst.
Read an Editorial Comment
Malignancy of the parathyroids is, of course, rare but may involve one or more parathyroids. Surgeons should decide in the operating room how radical a
procedure they will use and whether removal of adjacent anatomic entities is necessary.
Strategy for Finding Parathyroid Glands
The normal location of the superior and inferior parathyroid glands has been described. Traynor et al.233 found that rapid uptake of methylene blue by the
parathyroid glands suggests that selective intraoperative use when glands are difficult to locate intraoperatively, rather than a routine preoperative infusion,
is possible without significant operative delay. General surgeons must take specific steps to find the glands, however, because they cannot explore the entire
neck. The following steps are essentially those suggested by Adams,234 Cady,235 McGarity and Bostwick,236 and Edis:237
Step 1. Explore the superior surface of the thyroid gland. Ligate the middle thyroid veins, retract the lobe medially and anteriorly, and expose the recurrent
laryngeal nerve.
Step 2. Dissect the superior mediastinum as far as possible, with special attention to the thymus or its remnant behind the manubrium.
Step 3. Explore the region above the upper pole of the thyroid gland as far as the hyoid bone.
Step 4. Explore the retroesophageal and retropharyngeal spaces.
Step 5. Perform subtotal thyroidectomy.
Step 6. Further explore the mediastinum at a second operation. This should be done only after the pathology report on thymus and thyroid tissue has been
received and no parathyroid tissue is reported.236
The order of these steps, especially steps 5 and 6, is controversial. In a series of 400 operations reported by Nathaniels and colleagues,238 there were 84
mediastinal parathyroid tumors. Of these, 19 required mediastinotomy. Sixty-seven were in the anterior mediastinum, and 17 were in the posterior
mediastinum. The remainder were removed through a neck incision. We believe mediastinal exploration should be the procedure of last resort.
Surgical Applications
Preoperative localization of the parathyroid glands is a tremendous help for both patient and surgeon. Gupta et al.239 advise that preoperative 99m-technetium
sestamibi (MIBI) localization of simple parathyroid adenoma with hyperparathyroidisms will reduce not only operative time but also the extent of surgical dissection
and risk.
Farnebo et al.240 stated that Ki-67 (cell-cycle associated antigen) may give valuable information as to the malignant potential of parathyroid tumors, whereas
retinoblastoma protein immunoreactivity has not proven useful in distinguishing between benign and malignant parathyroid tumors.
Ryan et al.241 stated that after localization of the parathyroid adenoma a unilateral neck exploration produces results similar to bilateral exploration, and requires
less operative time.
Angelos et al.242 reported a very unusual case of a patient with hyperparathyroidism who experienced spontaneous left recurrent laryngeal nerve paralysis after
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Angelos et al.242 reported a very unusual case of a patient with hyperparathyroidism who experienced spontaneous left recurrent laryngeal nerve paralysis after
which his hypercalcemia resolved. After removal of a parathyroid adenoma with abscess formation the vocal cord function returned.
Richards et al.243 reported the ninth case of spontaneous infarction of a parathyroid adenoma in primary hyperparathyroidism. The anatomy of the infarction is
enigmatic. The above authors speculate that perhaps the infarction is secondary to the tumor outgrowing its blood supply. Thrombosis of the parathyroid blood
supply was reported by Dowlatabadi.244
Billingsley et al.245 used the term "parathymic" to designate an undescended parathyroid gland that is located high in the neck just below or above the carotid
bifurcation. Embryologically the term is correct, since the inferior parathyroids and the thymus arise from the third pharyngeal pouch. However, the term will confuse
the surgeon who is not familiar with the ontogenic location of the parathyroid glands and who may think it refers to a "thymic" location of the parathyroid.
For the treatment of familial hyperparathyroidism, Barry et al.246 advised subtotal parathyroidectomy and routine transcervical thymectomy.
Proye et al.247 stated that patients with primary hyperparathyroidism and multiple gland enlargement may be treated by conservative surgery, resecting only the
grossly enlarged glands and not biopsying the normal looking glands.
Chen et al.248 reported that parathyroidectomy in elderly patients (over 70 years) can be performed with high cures, low morbidity, no mortality, short length of
stay, and high patient satisfaction.
Pasieka and Parsons 249 reported that parathyroidectomy reduces preoperative symptomatology in patients with primary hyperparathyroidism, with the most
marked improvement occurring within the first 10 days after surgery.
Ryan and Lee 250 emphasized the effectiveness and safety of 100 consecutive parathyroidectomies in normalizing serum calcium.
Angelos 251 studied patients with primary hyperparathyroidism who were evaluated by preoperative scintigraphy. After excluding several patients based on their
histories, the remaining patients with positive scans underwent successful radioguided operations, while those with negative scans had successful standard
parathyroidectomies. Angelos concluded, "Although radioguided parathyroid surgery is an effective surgical approach...[s]tandard four gland exploration will continue
to be needed for many patients."
Miccoli et al.252 recommended endoscopic parathyroidectomy after preoperative localization of parathyroid lesions and intraoperative parathyroid hormone assay.
They had good results in 39 patients.
Starr et al.253 reported that intraoperative measurement of intact parathyroid hormone to measure adequacy of resection of hyperfunctioning tissue during
parathyroidectomy decreased the harvesting of frozen sections, but did not improve the rate of normalization of serum calcium.
Zaraca et al.254 stated that total parathyroidectomy with autotransplantation in 19 patients with severe secondary (renal) parathyroidism relieves the
hyperthyroidism symptoms, and the recurrence rate of hyperparathyroidism is low.
Mollerup and Lindewald 255 stated that primary hyperparathyroidism and renal stone disease are common, but a number of patients experience recurrence of their
stone disease in the presence of normal calcium rates after successful parathyroidectomy.
Caccitolo et al.256 believe that the correction of postexploration hypocalcemia using cryopreservation and autotransplantation is sound in theory, but difficult in
practice.
Since hyperparathyroidism may develop after autotransplantation of histologically normal parathyroid tissue, or after a period of postsurgical hypoparathyroidism,
D'Avanzo et al.257 stresses the importance of marking the site of parathyroid transplantation.
Using endoscopic laser technology, Stojadinovic et al.258 removed a parathyroid adenoma which was located in the piriform recess.
Although long periods of remission are possible after subtotal parathyroidectomy, Burgess et al.259 reported that recurrent hyperparathyroidism eventually
develops in most patients with multiple endocrine neoplasia type I (MEN I).
Rates of successful surgery for primary hyperparathyroidism are shown in Table 1-12.
Kikumori et al.260 reported that grafting of the parathyroids with total thyroidectomy is successful and that the glands fuction for a long time.
Table 1-12. Successful Surgery for Primary Hyperparathyroidism
Procedure
Success Rate Investigator
Initial operation
95%
Clark et al.351
Edis et al.352
Martin et al.353
Granberg et al.354
Reoperation without localization prior to surgery
60%
Satava et al.355
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Reoperation with localization prior to surgery by noninvasive techniques 89%
Satava et al.
Grant et al.356
NOTE: According to Cheung et al.357 and Sugg et al.,358 invasive techniques such as arteriography and selective venous sampling fail to localize the abnormal
parathyroid gland.
ANATOMIC COMPLICATIONS OF PARATHYROIDECTOMY
The complications of parathyroidectomy are the same as those associated with thyroidectomy (previously considered in this chapter) and radical neck
surgery (to follow later in this chapter).261,262
Failure to find an adenomatous gland in the presence of hyperparathyroidism is evidence of an inadequate procedure. Hellström and Ivemark263 reported
failure to find the diseased gland in 10 percent of 92 patients.
To avoid repeated parathyroidectomies, Shen et al.208 advised bilateral cervical exploration and preoperative localization.
Lo and Lam264 advised immediate autotransplantation of parathyroid glands to avoid hypoparathyroidism. The same authors cautioned that routine
autotransplantation was associated with a high incidence of postsurgical hypocalcemia.265
Berger et al.266 stated the following:
There is a marked heterogeneity in gland size in patients with sporadic multigland hyperplasia, which is similar to that found in multiple endocrine
neoplasia type I. This heterogeneity may result in failure to recognize multigland disease if a unilateral neck exploration is performed. Intraopertive
parathyroid hormone assay may prove to be an important adjunct in this population of patients who have unsuspected multigland disease.
TRACHEA AT THE NECK
EMBRYOGENESIS
Normal Development
There is confusion in the literature regarding the use of the terms ventral and dorsal wall of the foregut. Remember: the respiratory diverticulum appears at
the ventral wall of the foregut, but by separation later and the formation of the esophagopharingeal border, the foregut is divided in two portions: ventral,
which is responsible for the genesis of the respiratory system, and dorsal, which is responsible for the genesis of the esophagus.
At the end of the third week of gestation, the laryngotracheal groove appears on the ventral surface of the upper end of the embryonic foregut. The distal
end of the groove grows caudad, while the proximal end and the foregut grow cephalad. The trachea (anterior) and the esophagus (posterior) become
separated caudally; in the fourth week, the lung buds appear at the tip of the tracheal primordium. At first the tracheal bifurcation is high in the cervical
region; at birth it will be at the level of the 4th or 5th thoracic vertebra.
Cartilage appears in the trachea and primary bronchi in the tenth week, and glands appear a week later.267,268
Congenital Anomalies
The trachea is rarely subject to anomalies. Tracheoesophageal fistula is the only defect frequently encountered. Its repair does not fall into the field of the
general surgeon.
Vascular compression of the trachea was reported by Burch et al.269
SURGICAL ANATOMY
General Structure
The trachea, together with the esophagus and thyroid gland, lies in the visceral compartment of the neck. The anterior wall of the compartment is composed
of sternothyroid and sternohyoid muscles. It is covered anteriorly by the investing layer of the deep cervical fascia and posteriorly by the pretracheal fascia
(see Fig. 1-26). The trachea begins at the level of the sixth cervical vertebra. Its bifurcation is at the level of the sixth thoracic vertebra in the erect
position, or the fourth to fifth thoracic vertebrae when supine.
There are 16 to 20 tracheal cartilages. The cervical part of the trachea consists of 4 or 5 incomplete rings of cartilage and their connecting membranes,
smooth muscle fibers, and fibroelastic tissue completing the arches posteriorly. The smooth muscle fibers are arranged horizontally, attaching to the
perichondrium of the end of the cartilage. In this way, contraction of the muscle narrows the lumen of the trachea. The posterior surface of the trachea,
formed by the fibromuscular membrane, is therefore flat.
The cartilages are about 4 mm high and about 1 mm thick. In some cases the cartilages of two or more rings fuse, usually only partially. In some cases the
ends of the cartilage may bifurcate. The highest of the tracheal rings is attached to the cricoid cartilage by the cricotracheal membrane. This is the widest
of the tracheal cartilages. The diameter of the trachea is greater in men than in women, and is quite small in early childhood.
A subcutaneous tough band covering the laryngeal mucosa extends from the cricoid cartilage to the thyroid cartilage and to the vocal processes of the
arytenoid cartilages. This is the cricothyroid membrane or ligament, the site of emergency cricothyroidostomy.
The surgical anatomy of the cricothyroid membrane was studied by Dover et al.,270 who emphasized the importance of knowledge of the pathway of the
cricothyroid artery (Fig. 1-88). They stated that in 93 percent of individuals, this artery arose from the superior thyroid artery; it crossed the upper one-half
of the cricothyroid membrane in 14 out of 15 cadavers. In cricothyroidostomy the severed cricothyroid artery, or anastomosing branches, may bleed unseen
directly into the trachea, with possible aspiration and death. The authors also identified several veins crossing the membrane. Their findings on the
dimensions of the cricothyroid membrane are seen in Figure 1-89.
Fig. 1-88.
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Cricothyroid artery (arrow) traversing upper portion of cricothyroid membrane. (Modified from Dover K, Howdieshell TR, Colborn GL. The dimensions and vascular
anatomy of the cricothyroid membrane: relevance to emergent surgical airway access. Clin Anat 1996;9:291-295; with permission.)
Fig. 1-89.
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Dimensions of cricothyroid membrane. Range and (mean) values reported in millimeters. (Modified from Dover K, Howdieshell TR, Colborn GL. The dimensions and
vascular anatomy of the cricothyroid membrane: relevance to emergent surgical airway access. Clin Anat 1996;9:291-295; with permission.)
Vascular Supply
Arteries
The chief sources of arterial blood to the trachea are the inferior thyroid arteries. At the tracheal bifurcation, these descending branches anastomose with
ascending branches of the bronchial arteries.
Veins
Small tracheal veins join the laryngeal vein or empty directly into the left inferior thyroid vein. The inferior thyroid veins arise as a venous plexus on the
anterior surface of the isthmus of the thyroid gland. Left and right descending veins enter the respective brachiocephalic veins (see Fig. 1-58). The two
veins may form a common trunk entering the superior vena cava or the left brachiocephalic vein.
Lymphatics
The pretracheal and paratracheal lymph nodes receive the lymphatic vessels from the trachea.
Innervation
The trachealis muscle and the tracheal mucosa receive fibers from the vagus nerve, recurrent laryngeal nerves, and sympathetic trunks. Small autonomic
ganglia are numerous in the tracheal wall.
HISTOLOGY AND PHYSIOLOGY
The histology and physiology of the trachea is covered briefly in the chapter on the respiratory system.
SURGERY OF THE TRACHEA
The following are the most common procedures performed on the trachea:
Tracheostomy
Resection of malignant tumors (primary or secondary) or benign tumors
Associated benign or malignant tracheal compression for tumors close to the trachea-related anatomic entities
Treatment of tracheal stenosis
Treatment of tracheoesophageal fistulas (multiple procedures, see chapter on esophagus).
Anatomic Landmarks and Relations
The usual site of a tracheostomy is between the 2nd and 4th or 3rd and 5th tracheal rings. Several structures are encountered.
Beneath the skin, the platysma lies in the superficial fascia and is absent in the midline. The anterior jugular veins may lie close to the midline; more
importantly, they may be united by a jugular venous arch at the level of the seventh to eighth tracheal rings in the suprasternal space of Burns.
The investing layer of deep cervical fascia is encountered when the superficial fascia is reflected. Deep to the investing fascia are the sternohyoid and
sternothyroid muscles. These muscles lie between the investing layer and the pretracheal fascia on either side of the midline. They are retracted laterally.
There are several structures within the visceral compartment under the pretracheal fascia. The isthmus of the thyroid gland commonly lies at the level of the
second and third tracheal rings; it is frequently more cranial, less frequently more caudal. The isthmus can be retracted upward or downward to reach the
trachea; if necessary, it can be ligated and incised. In about 10 percent of individuals, the two lobes of the thyroid are not connected by an isthmus.
The possibility of a thyroid ima artery should not be forgotten. A suspensory ligament of the thyroid (see "Deep Fascia: Pretracheal Layer" describing the
fasciae of the neck previously in this chapter) and a levator thyroid muscle may also be present in, or close to, the midline.
Indications for Tracheostomy
Tracheostomy is performed following extensive operative procedures upon the neck when postoperative laryngeal edema exists, or as a concurrent procedure
when a total laryngectomy is performed, or following severe facial trauma. It may also be performed as an emergency procedure to establish an airway when
there is obstruction by a foreign body, laryngeal edema or postoperative vocal cord paralysis. It can be performed either above or below the isthmus of the
thyroid gland, although the lower approach is usually preferable. The isthmus can be retracted superiorly or divided between hemostats.
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thyroid gland, although the lower approach is usually preferable. The isthmus can be retracted superiorly or divided between hemostats.
A hook is usually placed beneath the cricoid cartilage in the midline to stabilize the trachea and pull it forward. The incision in the trachea can be performed
either in vertical or horizontal fashion; usually, however, the 3rd, 4th, and 5th tracheal rings are divided vertically from above downward. Today, the majority
of surgeons take a window out of the 2nd or 3rd ring. The incision is held open for insertion of the tracheostomy tube. It is important to select a tube of the
proper size so that pressure of the tube will not cause necrosis of the posterior tracheal wall.
After evaluating tracheostomy in 76 pediatric burn patients (newborn to three years of age), Coln et al.271 concluded that pediatric tracheostomy may be
performed safely without complications and with acceptable chronic morbidity.
When emergency tracheostomy is indicated, the procedure of choice is cricothyroidostomy. The procedure is very simple. After laryngeal stabilization, the
skin and subcutaneous tissue are incised by a short vertical incision. The membrane is palpated and incised transversely, then dilated. The tracheostomy
tube is inserted.
Maipang et al.272 performed mediastinal tracheostomies in 12 patients with advanced carcinoma of the lower neck and superior mediastinum.
ANATOMIC COMPLICATIONS
Tracheostomy
General Precautions
Ger and Evans273 related the anatomic complications of tracheostomy to the age of the patient and the location of the stoma. Neonates and infants have
more complications. The same authors described the complications that occur when tracheostomy is performed above or below the isthmus. The anatomic
landmark is the 1st tracheal ring, which is identified below the lower border of the cricoid cartilage and above the upper border of the isthmus. Of course, this
depends upon the thickness and width of the isthmus.
The space between the isthmus and the suprasternal notch is at the level of the 2nd or 3rd tracheal rings above and the 4th or 5th tracheal rings below.
High tracheostomy can produce tracheal stenosis; lower tracheostomy can also produce a galaxy of anatomic complications in adults and children.
Read an Editorial Comment
Remember
The brachiocephalic artery in adults lies anterolaterally to the right of the trachea and very close to the tracheal stoma. Fatal bleeding from injury was reported by
Silen and Spieker,274 Yang et al.,275 and Takano.276
Know the location of the left brachiocephalic vein. In children, the vein is located at the lowest part of the neck, just above the manubrium. In adults, it is located
behind the sternum at the upper half of the manubrium.
Inferior thyroid veins and the thyroid ima artery are located at the anterior wall of the trachea. They should be ligated to avoid bleeding.
Division of the thyroid isthmus is a good technique for avoiding complications.
Combined injuries of the trachea and esophagus should be repaired primarily. The sternocleidomastoid muscle can be used between the two repaired organs.277
Upadhyay et al.278 reported that tracheostomy can safely be performed without transporting the patient to the operating room. Their study of 470 patients showed
no significant difference in complications between the 311 patients (8.7%) who underwent bedside tracheostomy and the 159 patients (9.4%) who underwent
operating room tracheostomy.
If a drain is used, it should be brought out through a stab wound on the opposite side of the neck.
Vascular Injury
The following alerts you to several vessels that may bleed during tracheostomy.279
The anterior jugular veins may be encountered as the investing fascia is incised.
The venous thyroid plexus over the thyroid gland drains into the thyroid veins. The inferior thyroid veins drain inferiorly into the brachiocephalic veins, either forming
a single stem or draining separately. The inferior thyroid vein is often asymmetric, hence, more liable to injury.
The branches of the superior and inferior thyroid arteries may anastomose across the midline.
A thyroid ima artery is very occasionally present, and must be ligated if found.
The brachiocephalic artery and left brachiocephalic vein can be injured if sharp dissection is carried too far downward. The artery can be eroded by a tracheostomy
tube, resulting in a tracheoarterial fistula.
The subclavian artery and vein can be compromised by a tracheostomy tube that is incorrectly curved or placed too low (Fig. 1-90).
The common carotid artery can be injured when attempting a tracheostomy in the newborn. Moreover, it has been mistaken for the trachea. The left common carotid
artery may arise from the brachiocephalic trunk, thereafter crossing the lower part of the cervical trachea.
Fig. 1-90.
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Tracheostomy tubes: A, Tube too curved. The tracheal wall may be eroded and the subclavian artery may be occluded. B. Tube placed too low. Subclavian vessel
may be occluded. C, Tube with correct curvature correctly placed. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery.
New York: McGraw-Hill, 1983; with permission.)
Organ Injury
ESOPHAGUS
Injury to the esophagus usually occurs not from errors of perception of the anatomy, but from errors in the use of the tracheostomy tube. It is possible,
however, to create an iatrogenic tracheoesophageal fistula by careless manipulation.280
PNEUMOTHORAX AND PNEUMOMEDIASTINUM
Pneumothorax and pneumomediastinum also have been reported.
RECURRENT LARYNGEAL NERVES
Injury to these nerves can occur during tracheostomy as well as during thyroidectomy (see "Anatomic Complications of Thyroidectomy").
LARYNX
Too high a tracheostomy can result in direct injury to the vocal cords. Placement of the tube through the thyrohyoid membrane can also produce vocal cord
injury.279 The stoma should be formed below the first ring.
POSTTRACHEOSTOMY SWALLOWING DYSFUNCTION
The adverse effect of a cuffed tracheostomy tube on the swallowing mechanism was studied by Bonanno.281 Evaluation of the maxillary, glossopharyngeal,
recurrent, and external laryngeal nerves revealed that nerve injury was not a factor. Bonanno concluded that the dysfunction was produced by inhibition of
elevation and anterior rotation of the larynx and by failure of the hypopharyngeal sphincter to open completely.
Inadequate Procedures
An appreciation of the angle of the trachea to the surface of the neck is important in selecting a tube with the proper curvature. The distal end of a tube
with too much curvature will erode the anterior tracheal wall.185 Roe282 recommended a 60-degree curvature (Fig. 1-90).
Cricothyroidostomy
The anatomic complications of cricothyroidostomy are as follows:
Bleeding
Pneumomediastinum
Subcutaneous emphysema
Change of voice
Paresis of the vocal fold
Laryngeal fracture
Dysphonia
Subglottic stenosis
SALIVARY GLANDS
INTRODUCTION
The major salivary glands (parotid, submandibular, and sublingual) are shown in Fig. 1-91.
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The major salivary glands (parotid, submandibular, and sublingual) are shown in Fig. 1-91.
Fig. 1-91.
Salivary glands and their ducts. Dissection showing the sublingual, submandibular (submaxillary), and parotid glands. Deep lateral view of the lingual region with the
body and part of the ramus of the mandible cut away to expose the glands and related structures. (Modified from Anson BJ (ed). Morris' Human Anatomy (12th ed).
New York: McGraw-Hill, 1966; with permission.)
Salivary choristomas, hamartomas, embryonic rests, and displaced surface glands within alveolar bone may develop into intraosseous salivary neoplasms.283
Ha et al.2 reported an unusual salivary gland choristoma in the middle ear space which appeared to be a developmental abnormality associated with
abnormalities of adjacent structures.
Parotid Glands
EMBRYOGENESIS
Normal Development
Early in the sixth week of development, the parotid duct appears as a solid outgrowth of the oral epithelium. It grows posteriorly, toward the ear, investing
the facial nerve (VII) with its branches. The solid cords subsequently become canalized, and the cells at the tips of the branches differentiate into secretory
acini.
Congenital Anomalies
Congenital absence of major salivary glands is rare. Martinez Subias et al.285 reported total agenesis of the parotid gland.
Accessory glandular tissue separated from the main gland is not rare. Parotid tissue may extend forward between the two pterygoid muscles ("pterygoid
lobe") and upon the masseter muscle ("accessory lobe"), and occasionally forms even more medially on the buccinator muscle.
We agree with Anson and McVay286 that accessory tissue is common (20%). Most common is a local aggregation of glandular tissue (the "socia parotis")
along the parotid duct, into which the small ducts of the accessory tissue empty. These accessory parotid tissues have their own blood supply from the
transverse facial artery.
SURGICAL ANATOMY
General Relations
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The parotid gland lies beneath the skin, in front of and below the ear. It is contained within the investing layer of the deep fascia of the neck, called the
parotid fascia. It is separated from the submandibular gland by a fascial thickening, the stylomandibular ligament.
The parotid gland occupies the parotid space, the boundaries of which are:
Anterior: Masseter muscle, ramus of the mandible, and medial pterygoid muscle
Posterior: Mastoid process, sternocleidomastoid muscle, and posterior belly of the digastric muscle and facial nerve
Superior: External auditory meatus, and temporomandibular joint
Inferior: Sternocleidomastoid muscle, and posterior belly of the digastric muscle
Lateral: Investing layer of the deep cervical fascia, skin, and platysma muscle
Medial: Investing layer of the deep cervical fascia, styloid process, internal jugular vein, internal carotid artery, and pharyngeal wall
From the anterolateral edge of the gland, the parotid duct (Stensen's) passes lateral to the masseter muscle. It turns medial at the anterior margin of the
muscle, where it is related to the buccal fat pad or "boule de Bichat" (Fig. 1-92). The buccal pad is located medial to the parotid duct, between the masseter
and buccinator muscles.287 The buccinator muscle is pierced by the duct. It enters the oral cavity at the level of the upper second molar tooth. Accessory
parotid tissue may extend along the parotid duct. A short accessory duct may enter the main duct.286,287
Fig. 1-92.
The anatomic relations of the buccal pad of fat. (Modified from Tostevin PMJ, Ellis H. The buccal pad of fat: a review. Clin Anat 1995;8:403; with permission.)
Some authors41,77 described three surfaces (lateral, anterior, and posterior), three borders (anterior, medial, and superior), and two extremities (superior or
base, and inferior or apex).
There has long been controversy about the lobes of the parotid gland. Two important studies, which both appeared in 1956, illustrate the problem. Davis and
coworkers288 concluded that there is a superficial lobe and a deep lobe of the gland; the branches of the facial nerve run between them. In contrast,
Winsten and Ward289 visualized the gland as essentially unilobar; the branches of the facial nerve are "intimately enmeshed within the gland tissue," with no
cleavage plane between the nerve and gland. Beahrs23 agreed with the unilobar concept, as did Hollinshead.36 The view that one accepts does not change
the surgical procedure of superficial parotidectomy.
Poncet et al.290 stated that the surgical division of the parotid gland into 3 parts, or "lobes," in relation to the facial nerve is a practical custom. We have
seen one lobe, or two lobes (superficial and deep). We think that the so-called third or fourth lobes are nothing but embryologic parotid segments.
Parotid Fascia
The parotid fascia is the splitting of the general investing layer that envelops both the parotid and submandibular (submaxillary) glands, forming the superficial
and deep layers. The superficial layer is dense and tough in comparison to the deep, which is thin and weak. However, the stylomandibular ligament between
the styloid process and the angle of the mandible is derived from the deep layer. It is tough, and separates the parotid from the submandibular gland.
The parotid space communicates medially with the lateral pharyngeal space and with the posterior area of the masticator space. The posterior area of the
masticator space contains the masseter muscle, the pterygoid muscles, the small pterygomandibular space and the space of the body of the mandible.
Since many intraparotid anatomic entities radiate from the gland, the surgeon should be familiar with all of them, especially those that must not be sacrificed.
Bed of the Parotid Gland
Complete removal of the parotid gland reveals the following structures (the acronym VANS may be helpful in remembering them):
One Vein: internal jugular
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Two Arteries: external and internal carotid
Four Nerves: glossopharyngeal (IX), vagus (X), spinal accessory (XI), hypoglossal (XII)
Four anatomic entities starting with "S": styloid process, and styloglossus, stylopharyngeus, and stylohyoid muscles.
The topography of VANS is as follows:
The internal jugular vein is located medial to the styloid process, positioned posteriorly.
Occasionally the external carotid artery is embedded within the deep lobe, but usually it is superficial.
The internal carotid artery can be found anterior to the internal jugular vein.
The styloid process in adults is approximately 2.5 cm long and its tip is located between the external and internal carotid arteries, just lateral to the tonsillar fossa.
An elongated styloid process (called Eagle's syndrome because Eagle described it in 1937) can cause throat, neck, or facial pain.
The glossopharyngeal nerve (IX) snakes around the stylopharyngeus muscle, spiraling around its posterior surface as it passes inferiorly and medially to the wall of
the pharynx.
The vagus nerve (X) is located under or, occasionally, between the internal jugular vein and the internal carotid artery. The origin of the superior laryngeal branch is
found in this vicinity.
The spinal accessory nerve (XI) is superficial and lateral to the carotid sheath.
The hypoglossal nerve (XII) is located superficial and medial to the carotid sheath.
In addition to the styloid process are the muscles beginning with "S": the styloglossus and stylopharyngeus, which are beneath the external carotid artery, and the
stylohyoid, which is above it.
Vascular Supply
Arteries
The external carotid artery (Fig. 1-93) enters the inferior surface of the gland and divides at the level of the neck of the mandible into the maxillary and
superficial temporal arteries. The latter gives rise to the transverse facial artery. Each of these branches emerges separately from the superior or anterior
surface of the parotid gland.
Fig. 1-93.
Diagrammatic representation of the relationship of the parotid gland to the branches of the external carotid artery. (Modified from Skandalakis JE, Gray SW, Rowe JS
Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
NOTE: An artery which has nothing to do with the parotid is the middle meningeal artery: it is a branch of the maxillary artery which arises slightly anterior to
the neck of the mandible in the infratemporal fossa. It enters the cranial cavity through the foramen spinosum and supplies blood to the dura mater within
the skull.
Veins
The superficial temporal vein (Fig. 1-94) enters the superior surface of the parotid gland. It receives the maxillary vein to become the retromandibular vein.
Still within the gland, the retromandibular vein divides. The posterior branch joins the posterior auricular vein to form the external jugular vein. The anterior
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Still within the gland, the retromandibular vein divides. The posterior branch joins the posterior auricular vein to form the external jugular vein. The anterior
branch emerges from the gland to join with the facial vein, thereby forming the common facial vein, a tributary to the internal jugular. Remember: the facial
nerve is superficial, the artery is deep, and the retromandibular vein lies between them.
Fig. 1-94.
Diagrammatic representation of the relationship of the parotid gland to tributaries of the external and internal jugular veins. (Modified from Skandalakis JE, Gray SW,
Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Lymphatics
The preauricular lymph nodes in the superficial fascia drain the temporal area of the scalp, upper face, lateral portions of the eyelids, and anterior pinna.
Parotid nodes within the gland drain the gland itself, as well as the nasopharynx, nose, palate, middle ear, and external auditory meatus. These nodes, in
turn, send lymph to the subparotid nodes and eventually to the nodes of the internal jugular vein and spinal accessory chains (see Table 1-2).
Marks291 discussed the number of lymph nodes in the parotid area. He reported finding 1 to 11 lymph nodes in 17 specimens of radical parotidectomy. His
opinion is that perhaps a significant number may be left in the skin flaps.
Innervation
Autonomic Nervous System
The parotid gland is innervated by the parasympathetic and sympathetic divisions of the autonomic nervous system.
The parasympathetic innervation of the parotid gland originates from the glossopharyngeal nerve. Its tympanic branch (the nerve of Jacobson) ascends into
the skull through a small tympanic canaliculus to reach the middle ear, where it enters into the formation of a nerve plexus on the promontory of the medial
wall of the middle ear cavity. This plexus consists of a mixture of sensory (pain) and autonomic fibers. The lesser (superficial) petrosal nerve (Fig. 1-95),
consisting of presynaptic parasympathetic neurons, emerges from this plexus, leaves the middle ear cavity, travels across the floor of the middle cranial
fossa, and then descends through the foramen ovale to reach the otic ganglion. The otic ganglion is suspended from the mandibular nerve, just inferior to the
foramen ovale. The presynaptic parasympathetic fibers of the lesser petrosal nerve synapse upon the neurons within the otic ganglion. The postsynaptic
parasympathetic fibers leave the ganglion, forming one of the two roots of the auriculotemporal nerve, which pass on either side of the middle meningeal
artery, near the foramen spinosum. Several branches of the auriculotemporal nerve pass into the parotid, carrying postsynaptic parasympathetic fibers to the
glandular units. Some of these fibers are delivered to the secretory units by branches of the facial nerve as it passes through the gland. The
parasympathetic fibers are secretomotor; when stimulated by sensory (or psychic) stimuli, these fibers elicit profuse, watery secretion of the gland (Fig. 196). Last 292 has a beautiful and pragmatic expression in which he stated that the secretomotor fibers reach the gland by "hitchhiking."
Fig. 1-95.
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Schema of the parasympathetic innervation of the parotid gland. Solid line, preganglionic pathway. Broken line, postganglionic pathway.
Fig. 1-96.
Secretomotor nerve to parotid gland. (Modified from Basmajian JV, Slonecker CE. Grant's Method of Anatomy [11th ed]. Baltimore: Williams & Wilkins, 1989; with
permission.)
The sympathetic supply to the parotid originates from spinal cord segments T1-T3 (Fig. 1-97). Fibers follow the vertebral roots of the three upper thoracic
nerves, then travel via white rami communicantes to the upper sympathetic thoracic trunk and upward to the cervical sympathetic, reaching the superior
cervical ganglion. From this, branches travel toward the external carotid artery forming a sympathetic plexus, whose fibers follow the branches of the
external carotid to reach the parotid gland. The primary function of the sympathetic system may be vasoconstriction.
Fig. 1-97.
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Sympathetic supply to the parotid gland. WRC, white rami communicantes.
Auriculotemporal Nerve
The auriculotemporal nerve, a branch of the mandibular division of the trigeminal cranial nerve, carries postganglionic parasympathetic fibers to the parotid
gland. The preganglionic parasympathetic fibers for the parotid are carried initially by the glossopharyngeal nerve and its lesser petrosal branch; the
postganglionics arise in the otic ganglion, just outside the skull, deep to the main stem of the mandibular division of the trigeminal nerve. In addition, the
auriculotemporal nerve is sensory to the external ear and ear canal, temporomandibular joint, and skin of the temporal part of the face. It traverses the upper
part of the parotid gland and emerges with the superficial temporal blood vessels from the superior surface of the gland (Fig. 1-98).
Fig. 1-98.
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Diagrammatic representation of the relations of the parotid gland to the facial nerve and its branches. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr.
Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Within the gland, the auriculotemporal nerve communicates with the facial nerve. The auriculotemporal nerve is, for all practical purposes, sensory and
secretory.
Usually the order of the structures from the tragus anteriorly is: the auriculotemporal nerve, superficial temporal artery and vein, and temporal branch of the
facial nerve.
Related Nerves
Two nerves that are related to the parotid gland, but do not innervate it, are the facial nerve and the great auricular nerve.
FACIAL NERVE
The facial nerve has nothing to do with parotid innervation, but we present the nerve here because of its very close relationship with the parotid and salivary
glands.
The main trunk of the facial nerve (Fig. 1-98) enters the posterior surface of the parotid gland about 1 cm from its emergence from the skull through the
stylomastoid foramen, about midway between the angle of the mandible and the cartilaginous ear canal.
It is important to remember that at birth the child has no mastoid process; the stylomastoid foramen is subcutaneous. Therefore, the facial nerve's position
makes it particularly vulnerable.
About 1 cm from its entrance into the gland, the facial nerve typically divides to form five branches: temporal, zygomatic, buccal, mandibular, and cervical.
In most individuals, an initial bifurcation called the pes anserinus forms an upper temporofacial and a lower cervicofacial division, but six major patterns of
branching, based on a series of simple to complex arrangements, have been distinguished.288
In general, the nerve and its branches lie in a plane dividing the deep and superficial portions of the gland, but there is no true fascial plane between these
portions.
Beahrs23 suggested the following method to identify the facial nerve: The lower tip of the mastoid process is palpated and a fingertip is placed on the lateral
surface pointing forward. The trunk of the facial nerve will be found deep and anterior to the center of the fingertip.
The easiest method of identification takes a lateral approach. The insertion of the posterior belly of the digastric muscle is identified. The nerve is just medial
to the insertion point.
The styloid process is an unreliable landmark because of variations in its shape and size. Other landmarks for locating the facial nerve have been suggested,
e.g., the external auditory canal293 and the tympanomastoid suture.294,295
GREAT AURICULAR NERVE
The great auricular nerve arises from the second and third nerves of the cervical plexus. It reaches the posterior border of the sternocleidomastoid muscle
near the junction of the upper third and lower two-thirds of the muscle (Erb's point). Thereafter it passes obliquely upward and forward to the interval
between the earlobe and the angle of the mandible, roughly following the course of the external jugular vein (Fig. 1-98). It is usually sacrificed at
parotidectomy. Numbness in the preauricular region, the lower auricle, and the lobe of the ear results from injury to this nerve, but disappears after 4 to 6
months.
In summary, the branches of the facial nerve may be approximated by a radiating series of lines, each of which begins at the intertragic notch of the external
ear (Fig. 1-99):
Temporal branch: from notch to point "A" halfway between ear and lateral angle of the eye
Zygomatic branch: from notch to lateral angle of eye
Buccal branch: from notch to .5 cm above the labial tubercle of the upper lip
Cervical branch: from notch to a point ("B") halfway between the ear lobe and the angle of the mandible
Marginal mandibular: from notch to a point about 1 cm below the vascular notch of the mandible
Fig. 1-99.
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Superficial distribution of the facial nerve. Schematic representation of the typical positions of the branches of the facial nerve in relation to visible or palpable
topographic features of the face. A, indicates the midpoint of a line between the lateral angle of the eye and the anterior surface of the ear. A line from the
intertragic notch as shown will overlie the temporal branch. B, indicates the midpoint of a horizontal line drawn from the angle of the mandible to just below the lobe
of the ear. A line drawn from the intertragic notch to this midpoint overlies the typical course of the cervical branch.
The great auricular nerve may be used as a nerve graft.
SURGERY OF THE PAROTID GLAND
An inflammatory process of the parotid produces severe pain because of the tough unyielding superficial parotid fascia, which triggers pain fibers carried by the
auriculotemporal nerve. Since the parotid tissue extends into the retromandibular area, any movement of the jaw will produce severe pain. Remember the probable
cause of parotiditis (the 4 D's): debility, dehydration, depressed salivation, and dirty mouth.
Abscesses may be formed secondary to pharyngeal perforation or blood-borne infections. Stone formation within the duct and obstruction is another etiology of
abscess formation. The stone may be palpated (if large enough) within the mouth. The yielding deep parotid fascia may rupture; pus will travel to the retromandibular
space, temporomandibular joint, or external auditory canal. This abscess can be drained through the oral cavity or occasionally by a vertical incision of the skin and
elevation of the gland.
Chronic sclerosing sialadenitis, a chronic inflammatory condition of the salivary glands (especially the submandibular gland) which cannot be clinically distinguished
from a true neoplasm, is also known as Kuttner tumor. Williams et al.296 reported a case of Kuttner tumor of the submandibular and parotid glands exhibiting
widespread swelling.
Tunkel et al.297 stated that HIV infection has broad manifestations affecting the head and neck, and reported 5 seropositive patients with bilateral parotid
enlargement.
Parotid tumors may be benign or malignant. Most of the benign tumors are located in the superficial lobe and should be excised not by enucleation, but by
lobectomy. Malignant tumors should be treated by total parotidectomy; sacrifice the facial nerve if it is involved with the process.
We quote from James and Sharma 298 on parotid gland sarcoidosis:
Parotid gland sarcoidosis occurs in 6% of patients with sarcoidosis. It was bilateral in 24 (73%), slightly commoner in women, and presented in the
majority in the 20 to 40 year age group. There was widespread involvement of other systems, particularly intrathoracic, peripheral lymphadenopathy,
uveitis, lacrimal gland enlargement and skin disease. Patterns of involvement may be pathognomic as in Heerfordt's disease.
In patients with carcinoma of the parotid gland, Kelley et al.299 advise neck dissection only for those histologic diagnoses that carry the highest risk of nodal
metastases and for those patients whose primary tumor resection might be facilitated by lymphadenectomy. In other words, neck dissection should be performed
only when there are clinically enlarged nodes or when CT scan gives evidence of nodal involvement.
Renehan et al.300 analyzed treatment of patients with recurrent pleomorphic adenoma of the parotid gland. Those with multinodular recurrences are at high risk of
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relapse; they benefit from surgery with radiotherapy. Patients with uninodular recurrences may be adequately treated by surgery alone. A rare pleomorphic salivary
adenoma in an adolescent was reported by Forty and Wake.301
The syndrome of Frey (auriculotemporal nerve syndrome) consists of gustatory sweating and flushing of the ipsilateral face following parotidectomy, penetrating
wounds, or infection of the parotid. This condition may be caused by stimulation of the preauricular sweat glands. Irregular regeneration in the distribution of
auriculotemporal nerve fibers causes flushing and sweating to take place when eating, tasting, or smelling. The treatment of Frey's syndrome is section of the
glossopharyngeal nerve, which supplies the preganglionic fibers for the parotid gland.
Trauma in the parotid area can produce injury of the facial nerve or division of the parotid duct. Microsurgery is the procedure of choice for both. If this is not
possible for the duct, proximal and distal ligation is acceptable. For a salivary fistula, radiation may be indicated to produce atrophy of the gland.
A graft can be used for the facial nerve, employing the following nerves for donor tissue segments: the greater auricular, ilioinguinal, lateral femoral
cutaneous, and sural. The great auricular is the best because it is located in the same area and because its caliber is almost the same as that of the facial
nerve.
Remember that the facial nerve is superficial, a vein is under the nerve, and the artery is deepest.
Most of the tumors of the parotid are benign; most of the tumors of all the minor salivary glands are malignant.302 Why this is so is not known.
The most common procedure for a benign tumor is removal of the parotid lobe. Enucleation of the tumor is very tempting, but it is the wrong procedure because of
its high recurrence rate. Total parotidectomy for malignant tumors is the treatment of choice despite possible sacrifice of the facial nerve. With inflammatory process
and abscess formation an anatomic incision for draining is advised.
North et al.303 demonstrated the efficacy of postoperative irradiation for improving survival and local control in patients with carcinomas of the parotid and
submandibular glands.
In a review of pediatric neoplasms of the major salivary glands, Shikhani and Johns 304 recommended complete removal of the tumor at initial surgery (Tables 1-13,
1-14, and 1-15).
We strongly advise the surgeon interested in treatment of parotid and salivary cancers to study works of Johns and colleagues.305-308
Table 1-13. Benign Salivary Gland Neoplasms in Children (229 from Literature, 18 from Johns Hopkins)
Histology
Number
Percent
Pleomorphic adenoma
214
86.6
Plexiform neurofibroma
8
3.2
Warthin's tumor
5
2
Cystadenoma
5
2
Lymphoepithelial lesion
3
1.2
Neurilemmoma
3
1.2
Embryoma
3
1.2
Xanthoma
2
0.8
Adenoma
1
0.4
Total
247
100%
Source: Shikhani AH, Johns ME. Tumors of the major salivary glands in children. Head Neck Surg 1988;10:257-263; with permission.
Table 1-14. Malignant Salivary Gland Neoplasms in Children (243 from Literature, 3 from Johns Hopkins)
Histology
Number
Percent
Mucoepidermoid carcinoma
122
49.6
Acinic cell carcinoma
30
12.2
Undifferentiated carcinoma
22
8.9
Adenoid cystic carcinoma
16
6.5
Adenocarcinoma
19
7.7
Malignant mixed tumor
10
4.1
Rhabdomyosarcoma
6
2.4
Undifferentiated sarcoma
5
2.0
Mesenchymal sarcoma
5
2.0
Unclassified carcinoma
4
1.6
Squamous cell carcinoma
3
1.2
Lymphoma
3
1.2
Ganglioneuroblastoma
1
0.4
Total
246
100%
Source: Shikhani AH, Johns ME. Tumors of the major salivary glands in children. Head Neck Surg 1988;10:257-263; with permission.
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Table 1-15. Summary of Treatment and Outcome of 272 Cases in Childhood Salivary Gland Neoplasms
Histology
Initital Treatment
No. of Cases Recurrence NED (%)
DOD Follow-Up
Pleomorphic adenoma (parotid)
Superior parotidectomy
41
8 (19.5)
23/25 (92)
0
1-29 yrs
Total parotidectomy
14
1 (7.1)
14/14 (100) 0
4-22 yrs
Excision
56
22 (39.3)
45/50 (90)
1
1-49 yrs
Pleomorphic adenoma (submandibular)
Excision
21
4 (19)
21/21 (100) 0
3-25 yrs
Mucoepidermoid carcinoma (parotid)
Superior parotidectomy
13
4 (30.7)
11/11 (100) 0
2-17 yrs
Total parotidectomy
7
0 (0)
7/7 (100)
0.5-22 yrs
Excision
41
20 (48.8)
16/17 (94.1) 1
1-14 yrs
Excision & RT
5
0 (0)
5/5 (100)
0
1-5 yrs
Mucoepidermoid carcinoma (submandibular) Excision & RT
2
1 (50)
2/2 (100)
0
5.5 & 7 yrs
Acinic cell carcinoma (parotid)
Superior parotidectomy
1
0 (0)
1/1 (100)
Total parotidectomy
2
0 (0)
2/2 (100)
0
2 & 3 yrs
Excision
19
5 (26)
6/7 (85.7)
0
2-16 yrs
Superior parotidectomy
2
0 (0)
2/2 (100)
0
0.5 & 10 yrs
Total parotidectomy
4
2 (50)
2/4 (50)
2/4
0.5-18 yrs
Excision
9
5 (55.5)
3/7 (42.8)
4/7
10-51 yrs
Total parotidectomy
2
Adenoid cystic carcinoma (parotid)
Miscellaneous carcinoma*
Sarcoma (parotid)
0
4 yrs
1 (50)
1 (50)
1/2
2 mos-7 yrs
Total parotidectomy & RT 3
1 (33.3)
2/3 (66.6)
1/3
2-14 yrs
Excision
10
8 (80)
1/8 (12.5)
7/9
9 mos-8 yrs
Excision & RT
8
7 (87.5)
1/6 (16.6)
5/6
3-9 mos
RT alone
2
2 (100)
0 (0)
2/2
4-12 mos
Total parotidectomy
3
1 (33.3)
2/3 (66.6)
1/3
7-22 yrs
Total parotidectomy & RT 3
3 (100)
0
3
0.3-3 yrs
Excision & RT
3
3 (100)
0
3
6-8 mos
RT alone
1
1 (100)
0
1
15 mos
*Miscellaneous carcinomas undifferentiated, adeno, malignant mixed, and unclassified carcinoma
NED, no evidence of disease; DOD, dead of disease; RT, radiation therapy.
Source: Shikhani AH, Johns ME. Tumors of the major salivary glands in children. Head Neck Surg 1988;10:257-263; with permission.
ANATOMIC COMPLICATIONS
Vascular Injury
The major vessels crossing the parotid bed must be divided and ligated during parotidectomy. Bleeding from small vessels can result in hematoma.
Nerve Injury
The most commonly injured branches of the facial nerve are the buccal and mandibular; they also have few interconnections with other branches. The facial
nerve and its branches are obviously in danger during parotidectomy. They can be preserved only by careful observation and awareness of the previously
described anatomy. A stimulating electrode can be employed in verifying facial motor branches, causing muscle spasms when a nerve is contacted. The facial
trunk is large enough for anastomosis of the cut end, should this be necessary. A large cutaneous nerve of the calf (sural nerve) is often used in this
procedure to graft to the contralateral intact nerve. The smaller branches are injured more often and are much less easily sutured. No repair will completely
restore function. A traction injury may result in temporary paresis or permanent injury.
Brenner and Schoeller309 reported that the masseteric nerve, a branch of the mandibular nerve (Fig. 1-100), is a possible donor for facial nerve anastomosis
to restore function (closure of the mouth and eye) following facial nerve paralysis. Spira310 was perhaps the first to anastomose the masseteric nerve to the
facial nerve. The masseter muscle is denervated but its function, according to Brenner and Schoeller,309 may be taken over by the temporal muscle. Other
nerves used to restore facial nerve function are the hypoglossal, spinal accessory, and glossopharyngeal nerves.
Fig. 1-100.
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Diagram of the mandibular nerve in the region deep to the ramus of the mandible. In this lateral view the otic ganglion, situated on the medial side of the mandibular
nerve, is indicated in outline. The branch of the mandibular to the tensor veli palatini, which passes medially through the otic ganglion, is not shown. (Modified from
Hollinshead WH. Anatomy for Surgeons (2nd ed): Vol.1, The Head and Neck. New York: Harper & Row, 1968; with permission.)
Fournier et al.311 reported that the motor distribution of the mandibular nerve makes it a possibility for a masseteric-facial anastomosis to restore facial
function. They wrote, "The modest results and the side effects of the facio-hypoglossal anastomosis used for facial rehabilitation have led us to consider an
anastomosis between a motor branch of the trigeminal nerve and the facial nerve. Dissection has allowed us to demonstrate that the masseteric nerve offers
the characteristics and the relationships which should make such an anastomosis feasible."
Injury to the auriculotemporal nerve can produce Frey's syndrome, in which the skin anterior to the ear sweats during eating ("gustatory sweating";
considered previously under "Surgery of the Parotid Gland").
Submandibular Glands
EMBRYOGENESIS
The submandibular glands appear at approximately the end of the 6th week. The endoderm and oral epithelium in the floor of the primitive oral cavity are
responsible for the genesis of these glands. They are located lateral to the primitive tongue. Acini are formed around the 12th week. According to
Sperber,312 the glands also begin secreting at this time. The submandibular duct is formed later by the closure of a linear groove.
SURGICAL ANATOMY
The superficial portion of the submandibular gland is about 4 cm long, lying in the submandibular triangle superficial to the mylohyoid muscle. A tongue of
glandular tissue passes deep to the muscle, enveloping its posterior border to form the much smaller deep portion of the gland (see Fig. 1-18).
Important relationships of the superficial portion are: (1) the inferior surface is related to the facial vein and the cervicofacial branches of the facial nerve,
including the marginal mandibular and cervical rami; (2) the lateral surface is related to the facial artery; and (3) the medial surface is related to the
glossopharyngeal, lingual, and hypoglossal nerves.
The deep portion of the submandibular gland is related to the lingual nerve and submandibular ganglion above, and the hypoglossal nerve below (see Fig. 119).
The submandibular (Wharton's) duct emerges from the middle of the deep portion of the gland, crosses the sublingual space, and opens into the mouth on
the side of the frenulum of the tongue. Proximally it lies between the mylohyoid and hyoglossus muscles; distally it lies between the genioglossus muscle and
the sublingual gland.
The lingual nerve, a branch of the mandibular division of the trigeminal nerve (V), has a special relationship to the duct.25 The nerve lies first above and then
lateral to the duct, crossing below and then medial to it (see Fig. 1-19). The danger of injuring the nerve when sectioning the duct is obvious. The
hypoglossal nerve must also be protected inferior to the duct.
Marginal Mandibular Nerve
In about 50 percent of subjects, the mandibular branch of the facial nerve (marginal mandibular nerve) lies beneath the lower margin of the mandible. In the
remainder it lies below the mandible, posterior to the crossing of the facial artery16 (see Fig. 1-15). Ziarah and Atkinson,313 after dissecting 110 facial
halves, also reported that in more than half of their specimens the mandibular branch ran below the mandible and distal to the facial vessels.
It is important to note that the mandibular nerve is multiple in about 80 percent of individuals.17
SURGERY OF THE SUBMANDIBULAR GLANDS
With malignant tumors, total excision is mandatory. Occasionally the lingual and hypoglossal nerves should be sacrificed. With inflammatory process, abscess
formation, or lithiasis a very anatomic incision is advised.
ANATOMIC COMPLICATIONS
Vascular Injury
The vessels most frequently injured during excision of the submandibular glands are the facial (external maxillary) artery and vein. Martin314 suggested that
the facial artery or vein be exposed, sectioned, and ligated well below the edge of the mandible. The distal stump of the vessel is then dissected upward with
upward traction so that the marginal mandibular nerve is carried upward by the loop of the vessel. The artery and vein can be sutured to the underside of
the skin flap. This procedure will ensure ligation of these vessels before they are sectioned inadvertently.
Nerve Injury
Marginal Mandibular Nerve: The procedure outlined above for avoidance of vascular injury completely protects the mandibular nerve from subsequent injury.
If the mandibular branch of the facial nerve is injured it results in a flattening of the lower lip on the affected side. If a nerve stimulator is used to identify the
nerve, the anterosuperior portion of the platysma may contract. Depression of the corner of the mouth may also be observed. Dingman and Grabb17
discussed this response.
Hypoglossal Nerve: See "Radical Neck Dissection" following in this chapter.
Lingual Nerve: See "Radical Neck Dissection."
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Sublingual Glands and Other Salivary Glands
EMBRYOGENESIS
The sublingual glands appear around the 8th week. They originate from several epithelial buds of endodermal origin which are located at the paralingual
sulcus. The buds form multiple ducts by canalization.
SURGICAL ANATOMY
The paired sublingual gland (Figs. 1-101, 1-102) is an amygdaloid (almond-shaped), flat and narrow gland, smaller than the other major salivary glands
(parotid and submandibular). The sublingual gland is located under the mucosae of the floor of the mouth. Its boundaries are:
Superior: mucosa of the oral floor
Inferior: mylohyoid muscle
Anterior: sublingual gland of the other side
Posterior: deep process (anterior prolongation) of the submandibular (submaxillary) gland; rarely, this may be affixed to a secondary inflammatory process
Medial: lingual nerve, submandibular duct, and genioglossus muscle
Lateral: medial surface of the lower mandible
Fig. 1-101.
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Superficial and deep structures in the sublingual region. ("Right" and "left" indicate the side of the drawing.) A, Superficial Structures. The mucosa is intact on the
left; on the right, the region has been cleared of the vessels and nerves. B, Deep Structures. The vessels and nerves have been removed on the left, and on the
right the vessels and nerves are in situ.
Fig. 1-102.
Lateral view of the sublingual region. The body of the mandible has been removed.
This mucous gland has multiple ducts: 10 to 30, according to O'Rahilly,315 and 8 to 20, according to Gray's Anatomy.54 The ducts drain directly into the oral
cavity on the sublingual fold, with some of them entering the submandibular duct.
SURGERY OF THE SUBLINGUAL GLANDS AND OTHER SALIVARY GLANDS
A calculus may form within the substance of the gland (sialolith). The calculus can be removed through a mucosal incision, or the gland in toto can be
removed. The danger zone is the medial boundary where the submandibular duct and lingual nerve are located.
Another pathologic condition is the formation of a cyst or mucocele, the well-known ranula. Origination of the ranula is usually in the sublingual glands or
minor salivary glands, although it can appear in the submandibular duct. Removal of the cyst or the cyst plus the sublingual gland is advisable if partial
removal of the roof is not successful.
It is not within the scope of this book to present all the salivary glands, especially the so-called minor salivary glands (lingual, labial, buccal, palatal, etc.).
These are located in the mucosa or submucosa of the oral cavity. They are ductless or have minute, very short ducts.
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Since most tumors developing in sublingual and other salivary glands are malignant, en bloc resection is advised. Johns et al.73 characterized salivary gland
carcinomas as "infrequent in any single surgeon's experience."
HISTOLOGY AND PHYSIOLOGY OF THE SALIVARY GLANDS
The histology of the parotid, submandibular, and sublingual glands is the same. Each of these glands is composed of parenchymal elements (lobules which
form lobes) and connective tissue.
The basic anatomic and physiologic unit is the salivon, which consists of acinar cells, myoepithelial cells covering the acinar cells, and a duct that provides
the pathway for the saliva.
The histochemistry and morphology of oncocytic and oncocytoid tumors of the salivary gland was studied by Johns et al.316 and Paulino and Huvos.317
BRANCHIAL REMNANTS
EMBRYOGENESIS
Between the fourth and sixth weeks of gestation, the embryonic foregut changes from a flattened tube into a complicated series of structures, some of
which represent the primordia of the respiratory apparatus of our aquatic vertebral ancestors. In mammals these structures become rearranged and adapted
to new functions, or they disappear, leaving only occasional vestiges (Table 1-16).
Table 1-16. Derivatives of Branchial Arches and Pouches
Branchial
Arch
Derivatives
Pouch and Cleft Aortic Arch
I (maxillary
and
mandibular)
1st (transitory)
Cranial Fleshy Structures
Nerve
Skeletal Structures
V
Dorsal: incus
Anterior two-thirds of tongue
Anomalous
Remnants
Ventral: malleus, Meckel's cartilage
I
(hyomandibular)
II (hyoid)
Dorsal: auditory canal, tympanic
membrane, middle ear, eustachian
tube
2nd (transitory)
VII
Ventral:
cervicoaural
fistula
Dorsal: stapes
Ventral: styloid process, stylohyoid
ligament, lesser horn of hyoid bone
II
III
Pharyngeal and palatine tonsils
3rd
IX
III
IV
4th (left aortic arch; right
brachiocephalic)
X
IV
Cysts,
sinuses, and
fistulas
Posterior third of tongue, lingual tonsil Ventral: greater horn of hyoid bone
Dorsal: inferior parathyroids
Cysts,
Ventral: thymus
sinuses (rare)
Epiglottis, base of tongue
Ventral: thyroid cartilage
Dorsal: superior parathyroids
Cysts?
Ventral: thymus
V
5th (transitory)
X
(Rare)
Ventral: cricoid, arytenoid cartilages
Ultimobranchial body (parafollicular
cells of thyroid)
VI
6th (proximal pulmonary
artery, distal ductus
arteriosus)
Cysts?
Tracheal cartilage
Source: Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.
In other sections of this chapter we have discussed structures adapted to new functions: the thyroid and parathyroid glands and the ultimobranchial bodies.
Here we are concerned with structures that normally disappear during embryonic life. These are the ectodermal clefts and the endodermal pouches of the
pharynx.
Of these gill-like organs, only the dorsal portion of the first cleft and first pouch persist —as the external auditory meatus from the former and the middle ear
and eustachian tube from the latter.
SURGICAL ANATOMY
Fistulas
Fistulas are patent ductlike structures that have both external and internal orifices.
Cervicoauricular fistulas extend from the skin at the angle of the jaw, and may open into the external auditory canal. These fistulas lie anterior to the facial
nerve. They are remnants of the ventral portion of the first branchial cleft (Fig. 1-103).
Fig. 1-103.
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Congenital cervicoaural fistula or cyst. This is a persistent remnant of the ventral portion of the first branchial cleft. The tract may or may not open into the external
auditory canal. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Lateral cervical fistulas almost always arise from the ventral portion of the second branchial cleft and pouch. They originate on the lower third of the neck on
the anterior border of the sternocleidomastoid muscle. The orifice may be pigmented. The path is upward through the platysma muscle and deep fascia.
Above the hyoid bone the track turns medially to pass beneath the stylohyoid and the posterior belly of the digastric muscle, in front of the hypoglossal
nerve, and between the external and internal carotid arteries. It enters the pharynx on the anterior surface of the upper half of the posterior pillar of the
fauces (Fig. 1-104A). It may open into the supratonsillar fossa or even into the tonsil itself.
Fig. 1-104.
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Track of a second pouch and cleft fistula passing from the tonsillar fossa of the palatine (faucial) tonsils to the neck. A, Complete fistula. B, External (cervical) and
internal (pharyngeal) sinuses. C, Cyst of branchial cleft origin lying in the carotid notch. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications
in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Sinuses
Internal sinuses are blindly ending spaces that extend outward from openings in the pharynx; external sinuses are blindly ending spaces that extend inward
from openings in the skin.
Internal sinuses are usually asymptomatic and, hence, undetected.318 External sinuses usually arise at the anterior border of the sternocleidomastoid muscle
and end in a cystic dilatation. Many such sinuses result from an infected cyst or previous incomplete excision of a cyst (Fig. 1-104B).
Cysts
Cysts are spherical or elongated spaces lying in the track of a branchial pouch or cleft and have no communication with the pharynx or skin.
Superficial cysts lie at the edge of the sternocleidomastoid muscle. Deeper cysts lie on the jugular vein or in the bifurcation of the carotid artery (Fig. 1104C). These are of branchial cleft origin and are lined with stratified squamous epithelium. Cysts on the pharyngeal wall deep to the carotid arteries are
usually of branchial cleft origin. They are lined with ciliated epithelium unless inflammatory or pressure changes have occurred (Fig. 1-105). Skandalakis and
Gray83 consider these embryonic structures in greater detail.
Fig. 1-105.
Incomplete closure of the second branchial cleft of the pouch may leave cysts: Type I, superficial, at the border of the sternocleidomastoid muscle. Type II, between
the muscle and the jugular vein. Type III, in the bifurcation of the carotid artery. Type IV, in the pharyngeal wall. Types I, II, and III are of second cleft origin; Type
IV is from the second pouch. M, sternocleidomastoid muscle; V, jugular vein; A, carotid artery. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical
Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
SURGERY OF THE BRANCHIAL REMNANTS
Surgery is the treatment of choice for all cysts, sinuses, and fistulas related to the branchial remnants.
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Branchial remnants originating in the piriform recess can cause recurrent fistulas or abscesses in the neck. Kim et al.319 recommend chemocauterization of
the internal opening to avoid recurrence from inadequate removal of the fistula tract.
ANATOMIC COMPLICATIONS
Vascular Injury
The external and internal carotid arteries just above the bifurcation of the common carotid artery are especially prone to injury while performing excision of
the branchial remnants, because a second cleft cyst or the path of a second cleft fistula will lie in the crotch of the bifurcation.
The following veins must be avoided or ligated during excision of the branchial remnants: the external jugular, anterior jugular, common facial, lingual, and
internal jugular.
Nerve Injury
A first cleft sinus or cyst passes over or under the facial nerve below and anterior to the ear. The cyst may displace the nerve either upward or downward.
When removing the cyst, the surgeon must be careful to protect the nerve.
Several nerves will be found above the pathway of a second cleft or pouch branchial fistula:
Mandibular branch of the facial nerve (protection of this nerve has been considered under "Submandibular Glands: Anatomic Complications")
Cervical branch of the facial nerve (the skin should be incised 4-5 cm below the mandibular angle)
Spinal accessory nerve (may be injured when trying to free a cyst or fistulous tract from the sternocleidomastoid muscle)
Descendens hypoglossi (superior root of the ansa cervicalis) (may be cut if necessary)
Hypoglossal nerve (the fistula crosses the nerve above the bifurcation of the common carotid artery)
Superior laryngeal nerves (see "Anatomic Complications of Thyroidectomy: Nerve Injury" for discussion of effects of injury)
Vagus nerve (lies parallel to the carotid artery [the fistula crosses the nerve near the level of the carotid bifurcation])
Organ Injury
The pharyngeal opening of a fistula or an internal sinus must be closed without producing a large iatrogenic defect. Remember that this is at or near the
tonsillar fossa. Uncontrolled bleeding can be a problem.
Inadequate Procedures
Drainage or aspiration of branchial cysts is useless, and will sooner or later result in infection. Removal of all epithelial tissue is the only cure.
RADICAL NECK DISSECTION
INTRODUCTION
A radical neck dissection involves complete excision of the primary lesion, together with all nonessential structures and their lymph nodes, collecting lymph
trunks, fascia, and fat. By definition radical neck dissection involves the levels of lymph nodes I to V, the SCM muscle, cranial nerve XI, and the internal
jugular vein. The bed of a radical neck dissection is bounded above by the inferior border of the mandible, below by the clavicle, posteriorly by the anterior
border of the trapezius muscle, and anteriorly by the midline.
In addition to lymphatic tissue, which must be removed as completely as possible, nonlymphatic tissue falls into three categories:
(1) structures that can be sacrificed with impunity;
(2) structures whose sacrifice is controversial, especially for cosmetic reasons; and
(3) structures that must be preserved unless directly invaded by cancer. Structures in these categories are listed in Table 1-17.
Table 1-17. Synopsis of Radical Neck Procedures
Structures May be Sacrificed
Controversial Must be Preserveda
Organs
Submaxillary gland, lower pole of
parotid gland
None
Thyroid gland, parathyroid glands
Muscles
Omohyoid, sternocleidomastoid
Platysma,
digastric,
stylohyoid
All other muscles
Vessels
External jugular vein, facial artery Internal
and vein, superior thyroid artery, jugular vein
lingual artery
External carotid artery, internal carotid artery, subclavian artery and vein, thoracic duct
Nerves
Anterior cutaneous C2-C3,
supraclavicular C3-C4, ansa
hypoglossi, great auricular nerve
Mandibular branch of facial nerve, superior laryngeal nerve, recurrent laryngeal nerve, facial nerve,
lingual nerve, hypoglossal nerve, phrenic nerve, vagus nerve, cervical sympathetic nerve, carotid sinus
nerves, brachial plexus, nerves to rhomboid and serratus muscles
a Unless
Spinal
accessory
nerve
invaded by cancer.
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Source: Skandalakis JE, Gray SW, Rose JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.
Radical neck dissection must be planned as a curative procedure. Because of the morbidity of sacrifice of cranial nerve XI, when nodes in the area are not
enlarged a modified neck dissection is attempted.
The Brazilian Head and Neck Cancer Study Group320 presented results of a trial comparing management of oral squamous carcinoma using modified radical
classical neck dissection and using supraomohyoid neck dissection. The report indicated that the recurrence and survival rates were similar with both
procedures. Supraomohyoid neck dissection was recommended as standard elective treatment for T2-T4 oral squamous cell carcinomas.
SURGICAL ANATOMY
Fascia
Superficial Cervical Fascia
The transverse cervical nerve, greater auricular nerve, lesser occipital nerve, and supraclavicular nerves must be sacrificed. The result is anesthesia of the
posterior scalp, neck, and shoulder.321
There is disagreement about the need for sacrificing the platysma muscle. Some would sacrifice the muscle routinely. Others believe that preservation of the
muscle minimizes scarring and "that once superficial lymphatics are involved, the carcinoma is so widely disseminated that nothing is gained by further
surgical procedures."23
Deep Cervical Fascia
The deep cervical fascia must be removed as completely as possible, because lymph nodes and lymphatic vessels are distributed primarily in the connective
tissue between the layers of the fascia. The carotid sheath and the internal jugular vein also should be sacrificed.
The sternocleidomastoid muscle is used in reconstruction of radical procedures of the neck, therefore knowledge of the blood supply of the muscle perhaps
will minimize the risk of muscle necrosis. Kierner et al.322 reported that "the arterial blood supply of the lower third of the sternocleidomastoid muscle is
constantly provided by a branch of the suprascapular artery."
Triangles
Anterior Triangle
Submental triangle: Remove the entire contents.
Submandibular triangle: Remove the submandibular gland and lymph nodes.
Carotid triangle: Remove the internal jugular vein. High ligation of the vein is facilitated by removal of the lower pole of the parotid gland. The great auricular nerve
and all superficial branches of the cervical nerves should be cut. All lymph nodes along the internal jugular vein must be removed. The final result is shown in Figure 1106.
Fig. 1-106.
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The completed radical dissection of the neck. Remaining structures may be removed if they are involved in malignant growth. (Modified from Skandalakis JE, Gray SW,
Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Posterior Triangle
Remove all tissue above the spinal accessory nerve without injuring the nerve. With blunt dissection, free the nerve from the underlying tissue. Ligate the
external jugular vein close to the subclavian vein, and transect the sternocleidomastoid and omohyoid muscles.
The area beneath the spinal accessory nerve is the "danger zone"23 of Beahrs. It contains several structures that must be identified and saved if possible:
the nerves to the rhomboid and serratus anterior muscles, the brachial plexus, the subclavian artery and vein, and the phrenic nerve with the anterior
scalene muscle between. The object of dissection in this area is to remove completely the transverse cervical (inferior horizontal) and spinal accessory
chains of lymph nodes.
The thoracic duct on the left and the lymphatic duct on the right lie in a mass of areolar connective tissue, deep to the sternocleidomastoid muscle and
posterolateral to the internal jugular vein. Some lymphatic trunks may open independently into the subclavian or jugular veins. They should be preserved if
possible, but if they have been injured, ligate them.
Between the internal jugular vein and the common carotid artery lies the ansa cervicalis, which innervates the strap muscles of the neck. This nerve is on or
in the carotid sheath medial to the internal jugular vein. It may be cut with impunity.
Nerves
Marginal Mandibular Nerve
The marginal mandibular nerve is located in a horizontal (transverse) orientation. It is found just above and superficial to the facial artery and vein, just under
the platysma muscle and above the deep cervical fascia.
Note
The cervical branch of the facial nerve can be cut with impunity since it innervates only the platysma muscle.
The marginal branch innervates the muscles of the lower lip (quadratus labii inferioris and mentalis). Therefore it should be protected not only for functional reasons
but also for cosmetic reasons, to avoid an abnormal facial expression and a highly asymmetrical mouth corner.
An incision in the skin 4-5 cm below the mandibular angle will protect the nerves.
Lingual Nerve
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Lingual Nerve
The lingual nerve, hypoglossal nerve, and the duct of the submandibular gland travel together above (deep to) the mylohyoid muscle. This trio can be seen
after retracting the posterior border of the mylohyoid muscle. The lingual nerve is first seen at a higher level than the submandibular duct; anteriorly,
however, it passes deep to the duct to reach the tongue. The hypoglossal nerve, the most inferior member of the trio, passes horizontally forward in the
upper part of the neck and enters the floor of the mouth by passing deep to the mylohyoid muscle. Thereafter, the hypoglossal nerve passes into the
substance of the tongue, distributing branches to its musculature.
The lingual nerve provides general sensory and taste fibers to the tongue; the hypoglossal nerve provides motor supply to all of the musculature of the
tongue except the palatoglossus, which is supplied by the vagus.
Hypoglossal Nerve
The hypoglossal nerve lies external to the hyoglossus muscle, under and deep to the submandibular gland on its way to the tongue, beneath the posterior
belly of the digastric muscle. This nerve has several fellow travelers, such as the hypoglossal vena comitantes and the lingual artery. The lingual artery
passes deep to the hyoglossus muscle to enter the substance of the tongue. Coursing beside the hypoglossal nerve, the lingual artery may be located above
or below the nerve. Beahrs23 stated that the hypoglossal nerve may be injured in this location. The result is that when protruding, the tongue deviates to
the paralyzed side. This is due to paralysis of all the intrinsic and extrinsic muscles of the tongue, excluding the palatoglossus.
Primary repair of the hypoglossal nerve by microsurgical technique is possible if the injury is recognized during surgery. When the hypoglossal nerve is used to
replace the injured facial nerve, the patient is advised to move the tongue to the injured side when trying to smile. Carney and Anderson323 reported
hypoglossal nerve and internal carotid artery entrapment resulting from an inflammatory process of the surrounding lymph nodes in the area where the nerve
is very close to the artery.
Vagus Nerve
Very rarely the vagus nerve is damaged during radical neck dissection. Even though the nerve is posterior to the common carotid artery and internal jugular
vein and not readily seen, the carotid triad, of which the vagus is a part, is easily recognized. However, if the vagus nerve is involved with tumor, its
sacrifice is necessary.
Phrenic Nerve
The phrenic nerve is located on the ventral surface of the anterior scalene muscle, deep to the prevertebral fascia. Crossing superficial to the nerve are the
lateral branches of the thyrocervical trunk; that is, the transverse cervical and suprascapular arteries. Unilateral paralysis of the hemidiaphragm after division
of the phrenic nerve is tolerated well.
Spinal Accessory Nerve
The pathway of this nerve in the posterior triangle is enigmatic and peculiar. Gordon et al.324 noted that the accessory nerve is vulnerable to injury despite
careful preservation during surgical dissection; it is quite vulnerable in the posterior triangle. Other workers325-327 also emphasized the vulnerability of the
nerve to injury, and cited the occurrence of muscle paralysis "without discernible cause." O'Brien328 reviewed the indications for modified cervical dissections
and methods of sparing the spinal accessory (and other) important regional nerves.
The spinal accessory nerve is said to be located between two layers of fascia and separated from the levator scapulae by a heavy dense fascia. We have
seen this occasionally. We noticed the nerve very close to the skin (0.5-1.5 cm) in the subcutaneous tissue of the posterior triangle. This is the reason that
the nerve is so vulnerable in this area. Its position can be approximated by a line drawn from a point two-thirds of the distance up the posterior border of the
sternocleidomastoid and by another point one-third of the distance up the anterior border of the trapezius.27 The nerve should be protected.329,330
The double layer (superficial and deep) of fascia in this area is also peculiar. The deep layer (prevertebral fascia) is dense, but the superficial layer (investing
layer) is very thin and occasionally unnoticeable. Therefore, we advise that the knife not be used after making the skin incision. Instead, using a hemostat,
carefully separate the tissues in the pathway of the nerve from the posterior border of the sternocleidomastoid muscle, moving obliquely toward the anterior
border of the trapezius muscle where the spinal accessory nerve disappears under the trapezius.
We have seen the spinal accessory nerve bifurcate and trifurcate prior to its disappearance under the trapezius, or bifurcate and trifurcate very close to the
posterior border of the sternocleidomastoid muscle. We have also seen the nerve end at the posterior border of the sternocleidomastoid muscle. The spinal
accessory receives contributions from the 2nd, 3rd, and 4th cervical nerves. Presumably these contributions are sensory in function. However, because of
contributions from C3-C5, some patients have trapezius function even when cranial nerve XI is sacrificed. The lower contributions can occur in the posterior
triangle.
Soo et al.331 stated that the exact motor innervation of the trapezius muscle is controversial. The spinal accessory nerve innervates practically all segments
(regions) of the muscle. However, when the spinal accessory ends in the SCM muscle, the innervation of the trapezius is via C3. In our experience, the
branch from the spinal accessory to the trapezius may diverge from the SCM, joining the branch from C3, thereafter descending to the trapezius.
Brown et al.332 recommended changing the name of the spinal accessory nerve to the spinal accessory nerve plexus, presumably due to the complexity of its
contributions and branching patterns. They noted that with loss of the nerve, paralysis of the trapezius resulted, with drooping and internal rotation of the
shoulder. Zibordi et al.333 presented a very good description of the results of injury to the accessory nerve.
Three to four lymph nodes are very closely associated with the spinal nerve in the posterior triangle. With severe lymphadenitis, the nerve may be fixed with
one lymph node, and accidentally severed during lymph node excisional biopsy in the posterior triangle. According to King and Motta,334 lymph node biopsy
was the predominant reason for injury to the accessory nerve in 37 cases. Brown et al.332 also observed that the accessory nerve was easily removed along
with a lymph node to which it was densely adherent. Donner and Kline335 noted that the spinal accessory nerve was the nerve most commonly injured by
accident.
Decker and DuPlessis336 reported that the occipital artery crossing the hypoglossal nerve gives off a sternomastoid branch which follows the spinal accessory
nerve. The occipital artery very consistently crosses superior to the hypoglossal nerve from anteromedial to posterolateral. As it does so, it gives off the
sternocleidomastoid artery. This artery reaches the muscle parallel with, but inferior to, the point of entrance of the spinal accessory nerve into the SCM.
Thus, this vessel can be helpful in locating the nerve.
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Thus, this vessel can be helpful in locating the nerve.
ANATOMIC COMPLICATIONS
Those who undertake [radical neck dissection] should be aware of the vital importance of an accurate anatomic knowledge of the field before
accepting the responsibility of the treatment of a patient with metastatic disease involving the neck area.—Southwick and Slaughter337
Vascular Injury
Kerth and associates321 stated that the vessels injured in a radical neck dissection are (in order of frequency): the internal and external jugular veins,
subclavian vein, thoracic duct, and carotid artery.
Internal and External Jugular Veins
The internal jugular vein should be ligated as close to the subclavian vein as possible. Venous return will then be through the vertebral, pharyngeal,
pterygoid, esophageal, deep cervical, and occipital venous plexuses. The most important of these is the vertebral plexus.338
Unilateral ligation of external and internal jugular veins produces transient cyanosis and edema of the head. Bilateral ligation or excision must be undertaken
with caution. Martin314 considered simultaneous bilateral ligation "standard procedure in selected cases." However, from the work of several authors,
Zarem339 calculated that there is a 20 percent mortality rate if ligation of both sides is done simultaneously. Zarem would allow at least one month between
ligations to permit the vertebral veins to compensate for increased venous flow.
Too much traction on the internal jugular vein can result in a tear at its lower end. The vein will then retract under the clavicle, requiring the midportion of
the bone to be removed in order to reach and ligate the vein.
Subclavian Vein
Several authors321,337,339 have warned of the danger of air embolism through the internal or external jugular veins or the subclavian vein. The subclavian
vein is the direct continuation of the axillary vein. It is related to the first rib and receives the external jugular vein at the area opposite the middle of the
clavicle. Immediate suturing of the veins is mandatory. The actual mortality rate from air embolism is not known. Pneumothorax and pneumomediastinum also
have been reported.
Thoracic Duct
Postoperative cervical chyle fistula may complicate neck dissection. Nussenbaum et al.340 recommend early operative intervention if the peak 24-hour
drainage is greater than 1000 mL without a prompt response to medical management. They advise that persistent low-output drainage after 10 days is
associated with a prolonged management course and treatment-related complications. Gregor341 advocates total parenteral nutrition to control fluid and
protein loss while avoiding flow of chyle. If the fistula does not resolve, fibrin glue with mesh and muscle flaps is usually successful in achieving closure.
Information about complications of injury to the thoracic duct will be found in the chapter on the lymphatics.
Carotid Artery
Many individuals will tolerate unilateral obstruction of the carotid artery, but this tolerance cannot always be determined prior to operation. Complete
unilateral obstruction of the internal carotid artery carries a great chance of mortality. Moore et al.342 stated that 23% of patients who underwent elective
carotid artery ligation suffered strokes and 17% died. Of the patients undergoing compulsory ligation, 50% suffered strokes and 38% died. Two patients out
of 4 with bilateral carotid artery ligations survived without complications. The axiom by Moore et al. is worth reprinting here:
. . .every effort should be made to preserve the integrity of this vessel [carotid artery], and, if its rupture is deemed inevitable, elective ligation is
preferable to ligation after exsanguinating hemorrhage.
Schmeidek et al.343 reported that all patients with unilateral internal carotid artery occlusion had recurring episodes of focal cerebral ischemia. The
postoperative course of superficial temporal artery-middle cerebral artery anastomosis was uneventful in 23 patients (82%).
Puttini et al.344 reported operative morbidity and mortality of 4.1% in cases of clinical carotid stenosis with contralateral stenosis.
Southwick and Slaughter337 mentioned a case in which the common carotid artery and the vagus nerve were accidentally included in a ligation of the internal
jugular vein.
Pressure from manipulation of the carotid sinus at the bifurcation of the carotid artery can result in serious hypotension. If such pressure cannot be avoided,
infiltration of the area with Xylocaine is suggested.339
Nerve Injury
Spinal Accessory Nerve
Section of the spinal accessory nerve (XI) denervates the trapezius muscle, limiting abduction of the arm and elevation of the shoulder. Subsequent wasting
of the muscle results in a "dropped shoulder." There may be "winging of the superior angle of the scapula." If removal of the nerve is considered unnecessary,
it must be protected from injury. Gordon and colleagues324 reported 17 cases of operations on the posterior triangle in which nerve injury occurred in spite of
care taken to prevent it.
If injury is recognized in the operating room, end-to-end microsurgical anastomosis is the procedure of choice; greater auricular nerve graft is often used. If
the injury is recognized postoperatively, then repair should be done as soon as possible. Repair after the 3rd or 4th month following injury will not be
successful. The sural nerve can be used as a graft if an end-to-end anastomosis is not possible. In comments to Donner and Kline, Hans-Peter Richter345
agreed with Gabel and Nunley346 that the results of nerve repair are far worse if repair is delayed more than 4 months after the initial injury. Tindall,347 in the
same comments, further observed that the nerve was very superficial, merely 1-1.5 cm from the surface of the skin, and thereby injured readily. She stated
that if it could be repaired early, an excellent prognosis could be anticipated.
External Laryngeal and Recurrent Laryngeal Nerves
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External Laryngeal and Recurrent Laryngeal Nerves
Occasionally, these nerves may be injured in radical neck dissection. Injury of the external laryngeal nerve produces inability to tense the cord. Injury of the
recurrent laryngeal results in a paramedian position of the cord, with airway problems.
Ramus Mandibularis of the Facial Nerve
The ramus mandibularis of the facial nerve need not be injured if it is identified and protected. To preserve the nerve, place the incision 4-5 cm below the
angle of the mandible (this also protects the cervical branch). Remembering that the nerve is always above the facial vessels will assist in identification.
Other branches of the facial nerve, and the facial nerve trunk itself should be avoided unless their section is necessary for a tumor of the parotid gland.
We quote from Saffold et al.348:
[S]elective neck dissection performed in a manner preserving the cervical root branches has a small, predictable impact on sensation of the face and
neck. The upper anterior neck between each facial notch of the mandible is the region typically rendered anesthetic. Sacrifice of the cervical root
branches results in a significant extensive sensory deficit involving the entire ipsilateral neck.
Brown et al.349 suggested that the unpredictable postoperative pain and dysfunction that may follow radical neck surgery is likely secondary to the violation
of the blood supply of cranial nerves IX, X, XI and XII, and stressed the importance of sparing as many nerves and vessels as possible.
Brachial Plexus
The upper cord of the brachial plexus is most frequently injured when the connective tissue of the retroclavicular space is removed.337
Remember to preserve the following entities:
Marginal mandibular branch of the facial nerve
Lingual nerve
Hypoglossal nerve
Vagus nerve
Phrenic nerve
Spinal accessory nerve
However, if there is fixation with tumor, the above structures should be sacrificed.
Organ Injury
The thoracic duct can be safely ligated if it is injured. Some surgeons339 suggest routine ligation. The number of lymphatic trunks and their inconstant
anatomy makes it difficult to avoid lymphatic leakage.
Neck Deformity
Ducic and Hilger350 advise unilateral deep plane neck dissection to achieve better symmetry and lessen neck deformity following radical neck dissection.
REFERENCES
1. Eves A. Report of a case of suicidal wound of the throat with profuse haemorrhage successfully treated by ligature of the common carotid artery. Lancet
1849;1:556.
2. Larsen WJ. Human Embryology, 2nd Ed. New York: Churchill Livingstone, 1997, p. 356.
3. Gidvani VK, Bhowmick SK. Midline posterior cervical cystic hygroma. South Med J 1999;92:340-43. [PubMed: 10094282]
4. Miller MB, Cohn AS. Case report: fourth branchial pouch sinus. Ear Nose Throat J 1993;72:356. [PubMed: 8334967]
5. Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma 1979;19:391. [PubMed: 448778]
6. Roden DM, Pomerantz RA. Penetrating injuries to the neck: a safe, selective approach to management. Am Surg 1993;59:750. [PubMed: 8239198]
7. Atteberry LR, Dennis JW, Menawat SS, Frykberg ER. Physical examination alone is safe and accurate for evaluation of vascular injuries in penetrating Zone
II neck trauma. J Am Coll Surg 1994; 179:657. [PubMed: 7952477]
8. Biffl WL, Moore EE, Rehse DH, Offner PJ, Franciose RJ, Burch JM. Selective management of penetrating neck trauma based on cervical level of injury. Am J
Surg 174:678-682, 1997. [PubMed: 9409596]
9. Bumpous JM, Whitt PD, Ganzel TM, McClane SD. Penetrating injuries of the visceral compartment of the neck. Am J Otolaryngol 2000;21:190-194.
[PubMed: 10834554]
10. Demetriades D, Theodorou D, Cornwell E, Berne TV, Asensio J, Belzberg H, Velmahos G, Weaver F, Yellin A. Evaluation of penetrating injuries of the neck:
prospective study of 223 patients. World J Surg 1997;21:41-48. [PubMed: 8943176]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
113/125
5/24/2014
Print: Chapter 1. Neck
11. Britt LD, Cole FJ. "Alternative" surgery in trauma management. Arch Surg 1998;133:1177-1181. [PubMed: 9820347]
12. Sarikcioglu L, Demir S, Oguz N, Sindel M. Anomalous digastric muscle with three accessory bellies and one fibrous band. Surg Radiol Anat 1998;20:453454. [PubMed: 9932332]
13. Kopuz C, Ilgi S, Yavus S, Onderoglu S. Morphology of the retromandibular vein in relation to the facial nerve in the parotid gland. Acta Anat 1995;152:66.
[PubMed: 7604680]
14. Savary V, Robert R, Rogez JM, Armstrong O, Leborgne J. The mandibular marginal ramus of the facial nerve: an anatomic and clinical study. Surg Radiol
Anat 19:69-72, 1997. [PubMed: 9210238]
15. Basar R, Sargon MF, Tekdemir Y, Elhan A. The marginal mandibular branch of the facial nerve. Surg Radiol Anat 19:311-314, 1997. [PubMed: 9413079]
16. Skandalakis JE, Gray SW, Rowe JS Jr. Surgical anatomy of the submandibular triangle. Am Surg 1979;45:590. [PubMed: 507567]
17. Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg
1962;29:266. [PubMed: 13886490]
18. Wang TM, Lin CL, Kuo KJ, Shih C. Surgical anatomy of the mandibular ramus of the facial nerve in Chinese adults. Acta Anat 1991;142:126. [PubMed:
1781251]
19. Jovanovic MS. The mandibulo-stylohyoid ligament (tractus angularis). Surg Radiol Anat 1990;12:91. [PubMed: 2396186]
20. DuPlessis DJ. A Synopsis of Surgical Anatomy (11th ed). Bristol: Wright and Sons, 1975.
21. Sehirli Ü, Çavdar S. An accessory mylohyoid muscle. Surg Radiol Anat 1996;18:57-59. [PubMed: 8685814]
22. Lindner HH. The anatomy of the fasciae of the face and neck with particular reference to the spread and treatment of intraoral infections (Ludwig's) that
have progressed into adjacent fascial spaces. Ann Surg 1986;204:705. [PubMed: 3789840]
23. Beahrs OH. The surgical anatomy and technique of parotidectomy. Surg Clin North Am 1977;57:477. [PubMed: 325670]
24. Singhabhandhu B, Gray SW, Bryant MF, Skandalakis JE. Carotid body tumors. Am Surg 1973;39:501. [PubMed: 4725805]
25. Grant JCB, Basmajian JV. Grant's Method of Anatomy, 7th Ed. Baltimore: Williams & Wilkins, 1965, p. 553.
26. Kierner AC, Zelenka I, Heller S, Burian M. Surgical anatomy of the spinal accessory nerve and the trapezius branches of the cervical plexus. Arch Surg
2000;135:1428-1431. [PubMed: 11115348]
27. Kline DG, Hudson AR, Kim DH. Atlas of Peripheral Nerve Surgery. Philadelphia: WB Saunders, 2001.
28. Winnie AP. Plexus anesthesia. In: Winnie AP, Hakansson L, Buckhoj P (eds). Perivascular Techniques of Brachial Plexus Block (vol 1). Philadelphia: WB
Saunders, 1993.
29. Harry WG, Bennett JDC, Guha SC. Scalene muscles and the brachial plexus: anatomical variations and their clinical significance. Clin Anat 10:250-252,
1997. [PubMed: 9213042]
30. Kunkel JM, Machleder HI. Treatment of Paget-Schroetter disease. Arch Surg 1989;124:1153. [PubMed: 2529837]
31. Obuchowski AM, Ortiz AO. MR imaging of the thoracic inlet. Magn Reson Imaging Clin North Am 2000;8:183-203, ix-x.
32. Sanders RJ, Pearce WH. The treatment of thoracic outlet syndrome: a comparison of different operations. J Vasc Surg 1989;10:626. [PubMed: 2585651]
33. Makhoul RG, Machleder HI. Developmental anomalies at the thoracic outlet: an analysis of 200 consecutive cases. J Vasc Surg 1992;16:534-545.
[PubMed: 1404675]
34. Machleder HI, Moll F, Verity MA. The anterior scalene muscle in thoracic outlet compression syndrome. Arch Surg 1986;121:1141. [PubMed: 3767646]
35. Flye MW. Disorders of veins. In Sabiston DC Jr. Textbook of Surgery, 13th Ed. Philadelphia: WB Saunders, 1986, pp. 1709-1730.
36. Hollinshead WH. Anatomy for Surgeons (2nd ed). New York: Harper & Row, 1968.
37. Grodinsky M, Holyoke EA. The fasciae and fascial spaces of the head, neck and adjacent regions. Am J Anat 1938;63:367.
38. Coller FA, Yglesias L. The relation of the spread of infection to fascial planes in the neck and thorax. Surgery 1937;1:323.
39. Buser KB, Bart G. Surgical implications of the retropharyngeal space. Am Surg 1984;50:33. [PubMed: 6691632]
40. Pearse HE Jr. Mediastinitis following cervical suppuration. Ann Surg 1938;108:588.
41. Montgomery RL. Head and Neck Anatomy: With Clinical Correlations. New York: McGraw-Hill, 1981.
42. Johnson CA, Tollefson DFJ, Olsen SB, Andersen CA, McKee-Johnson J. The natural history of early recurrent carotid artery stenosis. Am J Surg
1999;177:433-436. [PubMed: 10365886]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
114/125
5/24/2014
Print: Chapter 1. Neck
1999;177:433-436. [PubMed: 10365886]
43. Lucev N, Bobinac D, Maric I, Drescik I. Variations of the great arteries in the carotid triangle. Otolaryngol Head Neck Surg 2000;122:590-591. [PubMed:
10740186]
44. Cole RD, May JS. Aberrant internal carotid artery. South Med J 1994; 87:1277. [PubMed: 7973930]
45. Papon X, Pasco A, Fournier HD, Mercier P, Cronier P, Pillet J. Anastomosis between the internal carotid and vertebral artery in the neck. Surg Radiol Anat
1995;17:335-337. [PubMed: 8896154]
46. Meder JF, Blustajn J, Trystram D, Godon-Hardy S, Devaux B, Zuber M, Frédy D. Radiologic anatomy of segmental agenesis of the internal carotid artery.
Surg Radiol Anat 19:385-394, 1997. [PubMed: 9479713]
47. Carsten CG III, Elmore JR, Franklin DP, Thomas DD, Mordan F, Wood GC. Use of limited color-flow Doppler duplex for a carotid screening project. Am J Surg
1999;178:174-177.
48. Wind GG, Valentine RJ. Anatomic Exposures in Vascular Surgery. Baltimore: Williams & Wilkins, 1991.
49. Roberts B, Hardesty WH, Holling HE, Reivich M, Toole JF. Studies on extracranial cerebral blood flow. Surgery 1964:56:826.
50. Dandy WE. Intracranial Arterial Aneurysms. Ithaca NY: Comstock, 1944.
51. Dandy WE. Results following bands and ligatures on the human internal carotid artery. Ann Surg 1946;123:384.
52. Pemberton JdeJ, Livermore GR Jr. Surgical treatment of carotid body tumors: value of anticoagulants in carotid ligation. Ann Surg 1951;133:837-852.
[PubMed: 14838528]
53. Drake CG, Peerless SJ, Ferguson GC. Hunterian proximal arterial occlusion for giant aneurysms of the carotid circulation. J Neurosurg 1994;81:656.
[PubMed: 7931611]
54. Kuehne JP, Weaver FA, Papanicolaou G, Yellin AE. Penetrating trauma of the internal carotid artery. Arch Surg 131:942-948, 1996. [PubMed: 8790179]
55. Blaisdell FW. Discussion. Kuehne JP, Weaver FA, Papanicolaou G, Yellin AE. Penetrating trauma of the internal carotid artery. Arch Surg 131:942-948,
1996.
56. Okamoto Y, Inugami A, Matsuzaki Z, Yokomizo M, Konno A, Togawa K, Kuribayashi R, Ogawa T, Kanno I. Carotid artery resection for head and neck
cancer. Surgery 120(1):54-59, 1996.
57. Marien BJ, Thompson RM. Anomalous branch of the cervical internal carotid artery. Contemp Surg 1998;53(5):332-334.
58. Ballotta E, Da Giau G, Renon L, Narne S, Saladini M, Abbruzzese E, Meneghetti G. Cranial and cervical nerve injuries after carotid endarterectomy: A
prospective study. Surgery 1999;125:85-91. [PubMed: 9889802]
59. Guterman LR, Fessler RD, Hopkins LN. Cervical carotid revascularization. Neurosurg Clin North Am 2000;11:39-48. [PubMed: 10565869]
60. Russell RCG, Williams NS, Bulstrode CJK (eds). Bailey & Love's Short Practice of Surgery (23rd ed). London: Arnold, 2000, p. 704.
61. Williams PL (ed). Gray's Anatomy (38th ed). New York: Churchill Livingstone, 1995.
62. Drinker CK, Yoffey JM. Lymphatics, Lymph, and Lymphoid Tissue. Cambridge MA: Harvard University Press, 1941, p 12.
63. Mancuso AA, Harnsberger HR, Muraki AS, Stevens MH. Computed tomography of cervical and retropharyngeal lymph nodes: normal anatomy, variants of
normal, and applications in staging head and neck cancer. Part I: normal anatomy. Radiology 1983:148:709.
64. Mancuso AA, Harnsberger HR, Muraki AS, Stevens MH. Computed tomography of cervical and retropharyngeal lymph nodes: normal anatomy, variants of
normal, and applications in staging head and neck cancer. Part II: pathology. Radiology 1983;148:715. [PubMed: 6878692]
65. Healey JE Jr. A Synopsis of Clinical Anatomy. Philadelphia: Saunders, 1969.
66. Kraus DH, Rosenberg DB, Davidson BJ, Shaha AR, Spiro RH, Strong EW, Schantz SP, Shah JP. Supraspinal accessory lymph node metastases in
supraomohyoid neck dissection. Am J Surg 172:646-649, 1996. [PubMed: 8988668]
67. Skandalakis JE, Androulakis JA. Swelling of the neck: a statistical analysis of 7,748 cases with emphasis on differential diagnosis of nonthyroid tumors. In:
Volume in Honor of BG Kourias. Athens, Greece: O Logos, 1975.
68. Lyles A, Johns ME, Johns MME. Fine needle aspiration of head and neck mass. In: Eiseman BE (ed). Cost-Effective Otolaryngology. New York: Decker,
1990, p. 179-186.
69. Feldman PS, Kaplan MJ, Johns ME, Cantrell RW. Fine-needle aspiration in squamous cell carcinoma of the head and neck. Arch Otolaryngol 1983;109:735742. [PubMed: 6639441]
70. Lee DJ, Rostock RA, Harris A, Kashima H, Johns M. Clinical evaluation of patients with metastatic squamous carcinoma of the neck with occult primary
tumor. South Med J 1986;79:979-983. [PubMed: 3738594]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
115/125
5/24/2014
Print: Chapter 1. Neck
71. Johns ME. The clonal assay of head and neck tumor cells: results and clinical correlations. Laryngoscope 1982;92(Suppl 28, No. 7, Pt. 2):1-26.
72. Johns ME, Mills SE. Cloning efficiency: a possible prognostic indicator in squamous cell carcinoma of the head and neck. Cancer 1983;52:1401-1404.
[PubMed: 6616405]
73. Johns ME, Mills SE, Thompson KK. Colony-forming assay of human salivary gland tumors. Arch Otolaryngol 1983;109:709-714. [PubMed: 6314953]
74. Davis HK. A statistical study of the thoracic duct in man. Am J Anat 1915:17:211.
75. Wechselberger G, Schoeller T, Otto A. Treatment of chronic thoracic duct fistula with the sternocleidomastoid muscle flap. Am J Surg 1998;176:471-474.
[PubMed: 9874436]
76. McGregor AL, DuPlessis DJ. A Synopsis of Surgical Anatomy, 10th Ed. Baltimore: Williams and Wilkins, 1969.
77. McVay CB. Anson & McVay Surgical Anatomy, 6th Ed. Philadelphia: WB Saunders, 1984.
78. Kuntz A. Distribution of the sympathetic rami to the brachial plexus. Arch Surg 1927;15:871-877.
79. Kuntz A. The Autonomic Nervous System (4th ed). Philadelphia: Lea & Febiger, 1953.
80. Platzer W. Atlas of Topographical Anatomy. Stuttgart: Georg Thieme Verlag, 1985.
81. Pearse AGE, Polak JM. Cytochemical evidence for the neural crest origin of mammalian ultimobranchial C cells. Histochemie 1971;27:96. [PubMed:
5092696]
82. Welbourn RB. Current status of the apudomas. Ann Surg 1977;185:1. [PubMed: 12724]
83. Skandalakis JE, Gray SW. Embryology for Surgeons (2nd ed). Baltimore: Williams & Wilkins, 1994.
84. LiVolsi VA. Developmental biology and anatomy of the thyroid, including the aberrant thyroid. In: Bennington JL (ed). Surgical Pathology of the Thyroid.
Vol 22 in the series Major Problems in Pathology. Philadelphia: WB Saunders, 1990, p. 7.
85. Gray SW, Skandalakis JE. Embryology for Surgeons (1st ed). Philadelphia: Saunders, 1972.
86. Kamat MR, Kulkarni JN, Desai PB, Jusswalla DJ. Lingual thyroid: a review of 12 cases. Br J Surg 1979;66:537. [PubMed: 486909]
87. Gray SW, Skandalakis JE, Androulakis JA. Nonthyroid tumors of the neck. Contemp Surg 26:13-24, 1985.
88. LiVolsi VA, Perzin KH, Savetsky L. Ectopic thyroid (including thyroglossal duct tissue). Cancer 34:1303-1315, 1974. [PubMed: 4421377]
89. Allard RHB. The thyroglossal cyst. Head Neck Surg 5:134-146, 1982. [PubMed: 7169333]
90. Nussbaum M, Buchwald RP, Ribner A, Mori K, Litwins JO. Anaplastic carcinoma arising from median ectopic thyroid (thyroglossal duct remnant). Cancer
48:2724-2728, 1981. [PubMed: 7306927]
91. Walton BR, Koch KE. Presentation and management of a thyroglossal duct cyst with a papillary carcinoma. South Med J 90(7):758-761, 1997.
92. Wang CY, Chang TC. Preoperative thyroid ultrasonography and fine-needle aspiration cytology in ectopic thyroid. Am Surg 61(12):1029-1031, 1995.
93. Stahl WM Jr, Lyall D. Cervical cysts and fistulae of thyroglossal tract origin. Ann Surg 1954;139:123. [PubMed: 13114863]
94. Quigley WF, Williams LF, Hughes CW. Surgical management of subhyoid median ectopic thyroid. Ann Surg 1962;155:305. [PubMed: 14489488]
95. Bhatnagar KP, Nettleton GS, Wagner CE. Subisthmic accessory thyroid gland in man: a case report and a review of thyroid anomalies. Clin Anat 10:341344, 1997. [PubMed: 9283734]
96. Monchik JM, Materazzi G. The necessity for a thoracic approach in thyroid surgery. Arch Surg 2000;135:467-471. [PubMed: 10768714]
97. Kumar R, Khullar S, Gupta R, Marwah A, Drm MA. Dual thyroid ectopy: case report and review of the literature. Clin Nucl Med 2000;25:253-254. [PubMed:
10750961]
98. LiVolsi VA. Surgical Pathology of the Thyroid. Philadelphia: WB Saunders, 1990.
99. Sawicki MP, Howard TJ, Passaro E Jr. Heterotopic tissue in lymph nodes: an unrecognized problem. Arch Surg 1990;125:1394. [PubMed: 2222180]
100. Rubenfeld S, Joseph UA, Schwartz MR, Weber SC. Ectopic thyroid in the right carotid triangle. Arch Otolaryngol Head Neck Surg 1988;114:913-915.
[PubMed: 3390337]
101. Woodruff JD, Rauh JT, Markley RL. Ovarian struma. Obstet Gynecol 1966;27:194. [PubMed: 5909538]
102. Kempers RD, Dockerty MB, Hoffman DL, Bartholomew LG. Struma ovarii: ascitic, hyperthyroid and asymptomatic syndromes. Ann Intern Med
1970;72:883-893. [PubMed: 5448747]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
116/125
5/24/2014
Print: Chapter 1. Neck
103. Yannopoulos D, Yannopoulos K, Ossowski R. Malignant struma ovarii. Pathol Ann 1976;11:403. [PubMed: 1004942]
104. Rosenblum NG, LiVolsi VA, Edmonds PR. Malignant struma ovarii. Gynecol Oncol 1989;32:224-227. [PubMed: 2910784]
105. Falor WH, Meyer EG, Bratcher E, Azarfahimi A, Sharp WV. The right thoracic duct in man: technique of exposure and variations in anatomy. Bull Akron
City Hosp 1963;5:1.
106. Polluck WF. Surgical anatomy of the thyroid and parathyroid glands. Surg Clin North Am 1964;44:1161.
107. Foster RS Jr, Hunter JG, Spivak H, Smith CD. Adrenal glands. In: Wood WC, Skandalakis JE. Anatomic Basis of Tumor Surgery. St. Louis: Quality Medical
Publishing, 1999, pp. 783-824.
108. Mastin EV. The blood supply of the thyroid gland and its surgical significance. Surg Gynecol Obstet 1923;36:69.
109. Nobori M, Saiki S, Tanaka N, Harihara Y, Shindo S, Fujimoto Y. Blood supply of the parathyroid gland from the superior thyroid artery. Surgery
1994;115:417-423. [PubMed: 8165531]
110. Weiglein AH. A rare variant of thyroid gland vascularization. Surg Radiol Anat 1996;18:233-235. [PubMed: 8873339]
111. Daseler EH, Anson BJ. Surgical anatomy of the subclavian artery and its branches. Surg Gynecol Obstet 1959;108:149. [PubMed: 13625063]
112. Hunt PS, Poole M, Reeve TS. A reappraisal of the surgical anatomy of the thyroid and parathyroid glands. Br J Surg 1968;55:63. [PubMed: 5635426]
113. Allan FD. An accessory or superficial inferior thyroid artery in a full term infant. Anat Rec 1952;112:539. [PubMed: 14924247]
114. Kriss JP, Konishi J, Herman M. Studies on the pathogenesis of Graves' ophthalmology (with some related observations regarding therapy). Recent Prog
Horm Res 1975;31:533. [PubMed: 1105721]
115. Földi M, Kukán F, Szegy G, Géllert A, Kozma M, Poberai M, Zoltan OT, Varga L. Anatomical, histological and experimental data on fluid circulation of the
eye. Acta Anat 1963;53:333. [PubMed: 16453386]
116. Mahorner HR, Caylor HD, Schlotthauer CF, Pemberton J de J. Observations on the lymphatic connections of the thyroid gland in man. Anat Rec
1927;36:341.
117. Gemsenjäger E, Heitz PU, Martina B. Selective treatment of differentiated thyroid carcinoma. World J Surg 21:546-552, 1997.
118. Feind CR. The head and neck. In: Haagensen CD, Feind CR, Herter FP, Slanetz CA Jr, Weinberg JA (eds). The Lymphatics in Cancer. Philadelphia:
Saunders, 1972.
119. Shaha AR, Shah JP, Loree TR. Patterns of nodal and distant metastasis based on histologic varieties in differentiated carcinoma of the thyroid. Am J
Surg 172:692-694, 1996. [PubMed: 8988680]
120. Katz AD, Nemiroff P. Anastomoses and bifurcations of the recurrent laryngeal nerve: report of 1177 nerves visualized. Am Surg 1993;59:188. [PubMed:
8476158]
121. Nemiroff PM, Katz AD. Extralaryngeal divisions of the recurrent laryngeal nerve. Am J Surg 1982;144:466-469. [PubMed: 7125080]
122. Skandalakis JE, Droulias C, Harlaftis N, Tzinas S, Gray SW, Akin JT Jr. Recurrent laryngeal nerves. Am Surg 1976;42:629. [PubMed: 949131]
123. Berlin DD. The recurrent laryngeal nerves in total ablation of the normal thyroid gland. Surg Gynecol Obstet 1935;60:19.
124. Schweizer V, Dörfl J. The anatomy of the inferior laryngeal nerve. Clin Otolaryngol 1997;22:362-369. [PubMed: 9298614]
125. Reed AF. The relations of the inferior laryngeal nerve to the inferior thyroid artery. Anat Rec 1943;85:17.
126. Lekacos NL, Tzardis PJ, Sfikakis PG, Patoulis SD, Restos SD. Course of the recurrent laryngeal nerve relative to the inferior thyroid artery and the
suspensory ligament of Berry. Int Surg 1992;77:287. [PubMed: 1478811]
127. Kreyer R, Pomaroli A. Anastomosis between the external branch of the superior laryngeal nerve and the recurrent laryngeal nerve. Clin Anat 2000;13:7982. [PubMed: 10679851]
128. Sturniolo G, D'Alia C, Tonante A, Gagliano E, Taranto F, Lo Schiavo MG. The recurrent laryngeal nerve related to thyroid surgery. Am J Surg
1999;177:485-488. [PubMed: 10414699]
129. Procacciante F, Picozzi P, Pacifici M, Picconi S, Ruggeri S, Fantini A, Basso N. Palpatory method used to identify the recurrent laryngeal nerve during
thyroidectomy. World J Surg 2000; 24:571-573.
130. Marchesi M, Biffoni M, Faloci C, Nobili Benedetti R, Notari P, Mariotti F, Cresti R. [The inferior nonrecurrent laryngeal nerve: a report of 7 cases observed
since 1987]. Giornale Chir 2000;21: 25-28. [PubMed: 10732377]
131. Avisse C, Marcus C, Delattre JF, Marcus C, Cailliez-Tomasi JP, Palot JP, Landam-Marcus V, Menanteau B, Flament JB. Right nonrecurrent inferior
laryngeal nerve and arteria lusoria: the diagnostic and therapeutic implications of an anatomic anomaly: Review of 17 cases. Surg Radiol Anat 1998;20:22732. [PubMed: 9706684]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
117/125
5/24/2014
32. [PubMed: 9706684]
Print: Chapter 1. Neck
132. Sanders G, Uyeda RY, Karlan MS. Nonrecurrent inferior laryngeal nerves and their association with a recurrent branch. Am J Surg 1983;146:501-503.
[PubMed: 6625095]
133. Miyauchi A, Matsusaka K, Kawaguchi H, Nakamoto K, Maeda M. Ansa-recurrent nerve anastomosis for vocal cord paralysis due to mediastinal lesions.
Ann Thorac Surg 1994;57:1020. [PubMed: 8166501]
134. Steinberg JL, Khane GJ, Fernandes CM, Nel JP. Anatomy of the recurrent laryngeal nerve: a redescription. J Laryngol Otol 1986;100:919. [PubMed:
3746108]
135. Herranz-Gonzalez J, Gavilan J, Martinez-Vidal J, Gavilan C. Complications following thyroid surgery. Arch Otolaryngol Head Neck Surg 1991;117:516.
[PubMed: 2021469]
136. Prioleu WH. Injury to the laryngeal branches of the vagus nerve in thyroid surgery. South Surg 1933;1:287.
137. Riddell V. Thyroidectomy: prevention of bilateral recurrent nerve palsy. Br J Surg 1970;57:1. [PubMed: 5411583]
138. Jatzko GR, Lisborg PH, Muller MG, Wette VM. Recurrent nerve palsy after thyroid operations: principal nerve identification and a literature review.
Surgery 1994;115:139. [PubMed: 8310401]
139. Wang C. The anatomic basis of parathyroid surgery. Ann Surg 183:271, 1976. [PubMed: 1259483]
140. Pelizzo MR, Toniato A, Gemo G. Zuckerkandl's tuberculum: an arrow pointing to the recurrent laryngeal nerve (constant anatomical landmark). J Am Coll
Surg 1998;187:333-336. [PubMed: 9740193]
141. Falk SA (ed). Thyroid Disease: Endocrinology, Surgery, Nuclear Medicine, and Radiotherapy, 2nd ed. Philadelphia: Lippincott-Raven, 1997.
142. Thompson NW. Thyroid gland. In Greenfield LJ (ed). Surgery: Scientific Principles and Practice. Philadelphia: Lippincott-Raven, 1997, pp. 1283-1308.
143. Dedo HH. The paralyzed larynx: an electromyographic study in dogs and humans. Laryngoscope 1970;80:1455. [PubMed: 4921200]
144. Sun SQ, Dong JP. An applied anatomical study of the superior laryngeal nerve loop. Surg Radiol Anat 1997;19:169-173. [PubMed: 9381318]
145. el-Guindy A, Abdel-Aziz M. Superior laryngeal nerve preservation in peri-apical surgery by mobilization of the viscerovertebral angle. J Laryngol Otol
2000;114;268-273.
146. Horiuchi M, Sasaki CT. Cricothyroid muscle in respiration. Ann Otol Rhinol Laryngol 1978;87:386.
147. Wu BL, Sanders I, Mu L, Biller HF. The human communicating nerve: an extension of the external superior laryngeal nerve that innervates the vocal cord.
Arch Otolaryngol 1994;120:1321. [PubMed: 7980895]
148. Cernea CR, Nishio S, Hojaij FC. Identification of the external branch of the superior laryngeal nerve (EBSLN) in large goiters. Am J Otolaryngol
1995;16:307. [PubMed: 7503373]
149. Cernea CR, Ferraz AR, Furlani. Identification of the external branch of the superior laryngeal nerve during thyroidectomy. Am J Surg 1992;164:634.
[PubMed: 1463114]
150. Cernea CR, Ferraz AR, Nishio S. Surgical anatomy of the external branch of the superior laryngeal nerve. Head Neck 1992; 14:380. [PubMed: 1399571]
151. Mooseman DA, DeWeese MS. The external laryngeal nerve as related to thyroidectomy. Surg Gynecol Obstet 1968;127:1011.
152. Ross MH, Reith EJ. Histology: A Text and Atlas. New York: Harper & Row, 1985, pp. 574-579.
153. Ferzli GS, Sayad P, Abdo Z, Cacchione RN. Minimally invasive, nonendoscopic thyroid surgery. J Am Coll Surg 2001;192:665-668. [PubMed: 11333106]
154. Bliss RD, Gauger PG, Delbridge LW. Surgeon's approach to the thyroid gland: surgical anatomy and the importance of technique. World J Surg
2000;24:891-897. [PubMed: 10865032]
155. Johns ME. The solitary thyroid nodule. Curr Ther Otolaryngol 1987;3:226-229.
156. Delbridge L, Guinea AI, Reeve TS. Total thyroidectomy for bilateral benign multinodular goiter. Arch Surg 1999;134:1389-1393. [PubMed: 10593340]
157. Cooper DS. Radioiodine for hyperthyroidism: where do we stand after 50 years? JAMA 280(4):375-376, 1998.
158. Ron E, Doody MM, Becker DV, Brill AB, Curtis RE, Goldman MB, Harris BSH III, Hoffman DA, McConahey WM, Maxon HR, Preston-Martin S, Warshauer ME,
Wong FL, Boice JD. Cancer mortality following treatment for adult hyperthyroidism. JAMA 280(4):347-355, 1998.
159. Skandalakis JE, Rand EO, Poer DH. Malignant tumors of the thyroid gland. J Med Assoc of Georgia 47(4):165-171, 1958.
160. Noguchi S, Noguchi A, Murakami N. Papillary carcinoma of the thyroid. I. Developing patterns of metastasis. Cancer 1970;26: 1053-1060. [PubMed:
5476786]
161. Mirallié E, Visset J, Sagan C, Hamy A, Le Bodic MF, Paineau J. Localization of cervical node metastasis of papillary thyroid carcinoma. World J Surg
1999;23:970-974.
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
118/125
5/24/2014
Print: Chapter 1. Neck
162. Clark OH. Invited commentary. Mirallié E, Visset J, Sagan C, Hamy A, Le Bodic MF, Paineau J. Localization of cervical node metastasis of papillary thyroid
carcinoma. World J Surg 1999;23:970-974.
163. Chen H, Nicol TL, Udelsman R. Clinically significant, isolated metastatic disease to the thyroid gland. World J Surg 1999;23: 177-181. [PubMed: 9880428]
164. Boyd LA, Earnhardt RC, Dunn JT, Frierson HF, Hanks JB. Preoperative evaluation and predictive value of fine-needle aspiration and frozen section of
thyroid nodules. J Am Coll Surg 1998;187:494-502. [PubMed: 9809565]
165. Tarantino DR, McHenry CR, Strickland T, Khiyami A. The role of fine-needle aspiration biopsy and flow cytometry in the evaluation of persistent neck
adenopathy. Am J Surg 1998;176: 413-417. [PubMed: 9874424]
166. Matsuzuka F, Fukata S, Kuma K, Miyauchi A, Kakudo K, Sugawara M. Gene rearrangement of immunoglobulin as a marker of thyroid lymphoma. World J
Surg 22:558-561, 1998. [PubMed: 9597928]
167. Smith P, Brown B, Gray SW, Skandalakis JE. Primary Hodgkin's disease of the thyroid gland. J Med Assoc Georgia, 75:538-540, 1986. [PubMed: 3772270]
168. Hermann M, Roka R, Richter B, Koriska K, Göbl S, Freissmuth M. Reoperation as treatment of relapse after subtotal thyroidectomy in Graves' disease.
Surgery 1999;125:522-528. [PubMed: 10330941]
169. Lo CY, Lam KY, Wan KY. Anaplastic carcinoma of the thyroid. Am J Surg 1999;177:337-339. [PubMed: 10326855]
170. Dhar DK, Kubota H, Kotoh T, Tabara H, Watanabe R, Tachibana M, Kohno H, Nagasue N. Tumor vascularity predicts recurrence in differentiated thyroid
carcinoma. Am J Surg 1998;176:442-447. [PubMed: 9874430]
171. Sanders LE, Silverman M. Follicular and Hürthle cell carcinoma: predicting outcome and directing therapy. Surgery 1998;124:967-974. [PubMed:
9854570]
172. Gauger PG, Reeve TS, Delbridge LW. Intraoperative decision making in follicular lesions of the thyroid: Is tumor size important? J Am Coll Surg
1999;189:253-258. [PubMed: 10472925]
173. Machens A, Hinze R, Lautenschläger C, Thomusch O, Dralle H. Thyroid carcinoma invading the cervicovisceral axis: routes of invasion and clinical
implications. Surgery 2001;129:23-28.
174. Gimm O, Ukkat J, Dralle H. Determinative factors of biochemical cure after primary and reoperative surgery for sporadic medullary thyroid carcinoma.
World J Surg 22:562-568, 1998. [PubMed: 9597929]
175. Hay ID, Grant CS, Bergstralh EJ, Thompson GB, van Heerden JA, Goellner JR. Unilateral total lobectomy: is it sufficient surgical treatment for patients
with AMES low-risk papillary thyroid carcinoma? Surgery 124:958-964, 1998. [PubMed: 9854569]
176. Dralle H, Gimm O, Simon D, Frank-Raue K, Görtz G, Niederle B, Wahl RA, Koch B, Walgenbach S, Hampel R, Ritter MM, Spelsberg F, Heiss A, Hinze R,
Höppner W. Prophylactic thyroidectomy in 75 children and adolescents with hereditary medullary thyroid carcinoma: German and Austrian experience. World J
Surg 22, 744-751, 1998.
177. Kebebew E, Kikuchi S, Duh QY, Clark OH. Long-term results of reoperation and localizing studies in patients with persistent or recurrent medullary thyroid
cancer. Arch Surg 2000;135:895-901. [PubMed: 10922248]
178. Voutilainen PE, Multanen M, Haapianen RK, Leppäniemi AK, Sivula AH. Anaplastic thyroid carcinoma survival. World J Surg 1999;23:975-979. [PubMed:
10449831]
179. Nilsson O, Lindeberg J, Zedenius J, Ekman E, Tennvall J, Blomgren H, Grimelius L, Lundell G, Wallin G. Anaplastic giant cell carcinoma of the thyroid gland:
treatment and survival over a 25-year period. World J Surg 1998;22:725-730. [PubMed: 9606289]
180. Hamoir E, Meurisse M, Defechereux T, Joris J, Vivario J, Hennen G. Surgical management of amiodarone-associated thyroxicosis: too risky or too
effective? World J Surg 22:537-543, 1998. [PubMed: 9597925]
181. Chao T-C, Lin J-D, Jeng L-B, Chen M-F. Thyroid cancer with concurrent hyperthyroidism. Arch Surg 1999;134:130-134. [PubMed: 10025449]
182. Shimizu K, Akira S, Jasmi AY, Kitamura Y, Kitagawa W, Akasu H, Tanaka S. Video-assisted neck surgery: Endoscopic resection of thyroid tumors with a
very minimal neck wound. J Am Coll Surg 1999;188:697-703. [PubMed: 10359365]
183. Yang CC, Lee CH, Wang LS, Huang BS, Hsu WH, Huang MH. Resectional treatment for thyroid cancer with tracheal invasion: a long-term follow-up
study. Arch Surg 2000;135:704-707. [PubMed: 10843368]
184. Pandya S, Sanders L. Use of a Foley catheter in the removal of a substernal goiter. Am J Surg 175:155-157, 1998. [PubMed: 9515535]
185. Conley JJ. Complications of Head and Neck Surgery. Philadelphia: Saunders, 1979.
186. Scanlon EF, Kellogg JE, Winchester DP, Larson RH. The morbidity of total thyroidectomy. Arch Surg 1981;116:568. [PubMed: 7235947]
187. Fernando DA, Lord RSA. The blood supply of the vagus nerve in the human: its implication in carotid endarterectomy, thyroidectomy and carotid arch
aneurectomy. Ann Anat 1994;176:333-337. [PubMed: 8085656]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
119/125
5/24/2014
aneurectomy. Ann Anat 1994;176:333-337. [PubMed: 8085656]
Print: Chapter 1. Neck
188. Holt GR, McMurry GT, Joseph DJ. Recurrent laryngeal nerve injury following thyroid operations. Surg Gynecol Obstet 1977; 144:567. [PubMed: 847613]
189. Lahey FH, Hoover WB. Injuries to the recurrent laryngeal nerves in thyroid operations. Ann Surg 1938;108:545.
190. Chang-Chien Y. Surgical anatomy and vulnerability of the recurrent laryngeal nerve. Int Surg 1980;65:23.
191. Esmeraldo R, Paloyan E, Laurence AM. Thyroidectomy, parathyroidectomy and modified neck dissection. Surg Clin North Am 1977;57:495.
192. Neel HB, Townsend GL, Devine KD. Bilateral vocal cord paralysis of undetermined etiology. Ann Otol 1972;81:514. [PubMed: 4341132]
193. Katz AD. Extralaryngeal division of the recurrent laryngeal nerve. Am J Surg 1986;152:407. [PubMed: 3766872]
194. Lekacos NL, Miligos ND, Tzardis PJ, Majiatis S, Patoulis J. The superior laryngeal nerve in thyroidectomy. Am Surg 1987;53:610. [PubMed: 3674608]
195. Durham CG, Harrison TS. The surgical anatomy of the superior laryngeal nerve. Surg Gynecol Obstet 1964;118:34.
196. Johns ME, Rood SR. Vocal Chord Paralysis: Diagnosis and Management. Washington DC: American Academy of Otolaryngology, 1987.
197. Harlaftis N, Tzinas S, Droulias C, Akin JT Jr, Gray SW, Skandalakis JE. Rare complications of thyroid surgery. Am Surg 1976;42:645-647. [PubMed:
949134]
198. Farquharson EL, Rintoul RF. Textbook of Operative Surgery (5th ed). Edinburgh: Churchill Livingstone, 1972.
199. Paparella MM, Shumrick DA. Otolaryngology (2nd ed). Philadelphia: WB Saunders, 1980.
200. Wilson TG. Diseases of the Ear, Nose and Throat in Children (2nd ed). London: William Heineman, 1962.
201. Stell PM, Maran AGD. Head and Neck Surgery (2nd ed). London: William Heineman, 1978.
202. Yerzingatsian KL. Surgical anatomy of structures adjacent to the thyroid apex and post-operative voice change (a review including dissection). J
Laryngol Otol Suppl 1987;14:1. [PubMed: 3320235]
203. Yerzingatsian KL. Thyroidectomy under local analgesia: the anatomical basis of cervical blocks. Ann R Coll Surg Engl 1989;71:207. [PubMed: 2774445]
204. Chao TC, Jeng LB, Lin JD, Chen MF. Reoperative thyroid surgery. World J Surg 21:644-647, 1997. [PubMed: 9230664]
205. Profanter C, Klingler A, Strolz S, Wetscher GJ, Promegger R, Bodner E, Riccabona G. Surgical therapy for primary hyperparathyroidism in patients with
previous thyroid surgery. Am J Surg 1999;178:374-376. [PubMed: 10612530]
206. Menegaux F, Turpin G, Dahman M, Leenhardt L, Chadaevian R, Aurengo A, du Pasquier L, Chigot JP. Secondary thyroidectomy in patients with prior
thyroid surgery for benign disease: a study of 203 cases. Surgery 1999;125:479-483.
207. Lundgren E, Ridefelt P, Äkerström G, Ljunhall S, Rastad J. Parathyroid tissue in normocalcemic and hypercalcemic primary hyperparathyroidism recruited
by health screening. World J Surg 20:727-735, 1996. [PubMed: 8678973]
208. Shen W, Düren M, Morita E, Higgins C, Duh QY, Siperstein AE, Clark OH. Reoperation for persistent or recurrent primary hyperparathyroidism. Arch Surg
131:861-869, 1996. [PubMed: 8712911]
209. Casas AT, Burke GJ, Mansberger AR Jr, Wei JP. Impact of Technetium-99m-sestamibi localization on operative time and success of operations for primary
hyperparathyroidism. Am Surg 1994;60:12. [PubMed: 8273968]
210. Malhotra A, Silver CE, Deshpande V, Freeman LM. Preoperative parathyroid localization with sestamibi. Am J Surg 172:637-640, 1996. [PubMed:
8988666]
211. Martin D, Rosen IB, Ichise M. Evaluation of single isotope technetium 99m-sestamibi in localization efficiency for hyperparathyroidism. Am J Surg
172:633-636, 1996. [PubMed: 8988665]
212. Farr HW, Fahey TJ Jr, Nash AG, Farr CM. Primary hyperparathyroidism and cancer. Am J Surg 1973;126:539. [PubMed: 4743840]
213. DiGiulio W, Morales JO. The value of selnomethionine Se75 scan in preoperative localization of parathyroid adenomas. JAMA 1969;209:1873. [PubMed:
5820075]
214. Bilezikian JP, Doppman JL, Shimkin PM. Preoperative localization of abnormal parathyroid tissue: cumulative experience with venous sampling and
arteriography. Am J Med 1973;55: 505. [PubMed: 4743348]
215. McIntyre RC, Eisenach JH, Pearlman NW, Ridgeway CE, Liechty RD. Intrathyroidal parathyroid glands can be a cause of failed cervical exploration for
hyperparathyroidism. Am J Surg 174:750-754, 1997. [PubMed: 9409611]
216. Libutti SK, Bartlett DL, Jaskowiak NT, Skarulis M, Marx SJ, Spiegel AM, Fraker DL, Doppman JL, Shawker TJ, Alexander HR. The role of thyroid resection
during reoperation for persistent or recurrent hyperparathyroidism. Surgery 122:1183-8, 1997. [PubMed: 9426436]
217. Gray SW, Skandalakis JE, Akin JT Jr, Droulias C, Vohman MD. Parathyroid glands. Am Surg 1976;42:653. [PubMed: 949136]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
120/125
5/24/2014
Print: Chapter 1. Neck
218. Hooghe L, Kinnaert P, Van Geertruyden J. Surgical anatomy of hyperparathyroidism. Acta Chir Belg 1992;92:1. [PubMed: 1553842]
219. Wei JP, Tippins RB, Rao RN, Burke GJ, Mansberger AR Jr. Nonadenomatous thymic unencapsulated parathyroid tissue as a cause of persistent primary
hyperparathyroidism. South Med J 1994;87:1264. [PubMed: 7973927]
220. McHenry CR, Lee K, Saadey J, Neumann DR, Esselstyn Jr CB. Parathyroid localization with technetium-99m-sestamibi: a prospective evaluation. J Am Coll
Surg 183:25-30, 1996. [PubMed: 8673304]
221. Bonjer HJ, Bruining HA, Pols HAP, de Herder WW, Proye CAG, Carnaille BML, Mohammedamin RSA, Steyerberg EW, Breeman WAP, Krenning EP. 2Methoxyisobutylisonitrile probe during parathyroid surgery: tool or gadget? World J Surg 22(6):507-512, 1998.
222. Purcell GP, Dirbas FM, Jeffrey RB, Lane MJ, Desser T, McDougall IR, Weigel RJ. Parathyroid localization with high-resolution ultrasound and technetium Tc
99m sestamibi. Arch Surg 1999;134:824-830. [PubMed: 10443804]
223. Szabo E, Lundgren E, Juhlin C, Ljunghall S, Äkerström G, Rastad J. Double parathyroid adenoma, a clinically nondistinct entity of primary
hyperparathyroidism. World J Surg 22:708-713, 1998. [PubMed: 9606286]
224. Krausz Y, Lebensart PD, Klein M, Weininger J, Blachar A, Chisin R, Shiloni E. Preoperative localization of parathyroid adenoma in patients with
concomitant thyroid nodular disease. World J Surg 2000;24:1573-1578. [PubMed: 11193726]
225. Alveryd A. Parathyroid gland in thyroid surgery. Acta Chir Scand (suppl) 1968;389:1. [PubMed: 5760870]
226. Delattre JF, Flament JB, Palot JP, Pluot M. [Variations in the parathyroid glands. Number, situation and arterial vascularization. Anatomical study and
surgical application]. J Chir (Paris) 1982;119:633. [PubMed: 7153263]
227. Ander S, Johansson K, Smeds S. Blood supply and parathyroid hormone secretion in pathological parathyroid glands. World J Surg 20(5):598-602, 1996.
228. Weber CJ, Russell J, Chryssochoos JT, Hagler M, McGarity WC. Parathyroid hormone content distinguishes true normal parathyroids from parathyroids of
patients with primary hyperparathyroidism. World J Surg 20:1010-1015, 1996. [PubMed: 8798358]
229. Cisneros G, Lara LF, Crock R, Whittier FC. Humoral hypercalcemia of malignancy in squamous cell carcinoma of the skin: parathyroid hormone-related
protein as a cause. South Med J 2001;94:329-331. [PubMed: 11284521]
230. Perez JB, Pazianos AG. Unusual presentation of primary hyperparathyroidism with osteoporosis, hypercalcemia, and normal parathyroid hormone level.
South Med J 2001;94:339-341. [PubMed: 11284524]
231. LiVolsi VA. Invited Commentary. In Luts L, Bergenfelz A, Alumets J, Sundler F. Parathyroid function and histology in patients with parathyroid adenoma:
correlation of clinical and morphologic findings. World J Surg 21:553-563, 1997.
232. Safran D. Functioning parathyroid cyst. South Med J 91(10):978-980, 1998.
233. Traynor S, Adams JR, Andersen P, Everts E, Cohen J. Appropriate timing and velocity of infusion for the selective staining of parathyroid glands by
intravenous methylene blue. Am J Surg 176:15-17, 1998. [PubMed: 9683125]
234. Adams HD. Parathyroid adenoma: problems of diagnosis and localization. Surg Clin North Am 1968;48:483. [PubMed: 5649782]
235. Cady B. Neck exploration for hyperparathyroidism. Surg Clin North Am 1973;53:301. [PubMed: 4693349]
236. McGarity WC, Bostwick J. Technique of parathyroidectomy. Am Surg 1976;42:657. [PubMed: 949137]
237. Edis AJ. Surgical anatomy and technique of neck exploration for primary hyperparathyroidism. Surg Clin North Am 1977;57:495. [PubMed: 867217]
238. Nathaniels EK, Nathaniels AM, Wang C. Mediastinal parathyroid tumors: a clinical and pathological study of 84 cases. Ann Surg 1970;171:165. [PubMed:
5413453]
239. Gupta VK, Yeh KA, Burke GJ, Wei JP. 99m-Technetium sestamibi localized solitary parathyroid adenoma as an indication for limited unilateral surgical
exploration. Am J Surg 1998;176: 409-412. [PubMed: 9874423]
240. Farnebo F, Auer G, Farnebo L-O, Teh BT, Twigg S, Asperblad U, Thompson NW, Grimelius L, Larsson C, Sandelin K. Evaluation of retinoblastoma and Ki67 immunostaining as diagnostic markers of benign and malignant parathyroid disease. World J Surg 1999;23:68-74. [PubMed: 9841766]
241. Ryan JA, Eisenberg B, Pado KM, Lee F. Efficacy of selective unilateral exploration in hyperparathyroidism based on localization tests. Arch Surg 132:886891, 1997. [PubMed: 9267274]
242. Angelos P, Thompson NW, Giordano TJ. Spontaneous vocal cord paresis and return to normocalcemia: an unusual presentation of parathyroid adenoma
with concomitant abscess. Surgery 121(6):704-707, 1997.
243. Richards ML, Thompson NW, Giordano TJ. Spontaneous infarction of a parathyroid adenoma in primary hyperparathyroidism: Case report and literature
review. Contemp Surg 1999; 54:292-296.
244. Dowlatabadi H. Acute fatal parathyroid poisoning associated with necrosis of the parathyroid adenoma prior to death. J Clin Endocrinol 19:1481-1485,
1959. [PubMed: 13817892]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
121/125
5/24/2014
Print: Chapter 1. Neck
245. Billingsley KG, Fraker DL, Doppman JL, Norton JA, Shawker TH, Skarulis MC, Marx SJ, Spiegel AM, Alexander HR. Localization and operative management
of undescended parathyroid adenomas in patients with persistent primary hyperparathyroidism. Surgery 1994;116:982. [PubMed: 7985106]
246. Barry MK, van Heerden JA, Grant CS, Thompson GB, Khosla S. Is familial hyperparathyroidism a unique disease? Surgery 122: 1028-1033, 1997. [PubMed:
9426416]
247. Proye C, Carnaille B, Quievreux J-L, Combemale F, Oudar C, Lecomte-Houcke M. Late outcome of 304 consecutive patients with multiple gland
enlargement in primary hyperparathyroidism treated by conservative surgery. World J Surg 22:526-530, 1998. [PubMed: 9597923]
248. Chen H, Parkerson S, Udelsman R. Parathyroidectomy in the elderly: do the benefits outweigh the risks? World J Surg 22:531-536, 1998. [PubMed:
9597924]
249. Pasieka JL, Parsons LL. Prospective surgical outcome study of relief of symptoms following surgery in patients with primary hyperparathyroidism. World J
Surg 1998;22:513-518. [PubMed: 9597921]
250. Ryan JA, Lee F. Effectiveness and safety of 100 consecutive parathyroidectomies. Am J Surg 173:441-444, 1997. [PubMed: 9168085]
251. Angelos P. An initial experience with radioguided parathyroid surgery. Am J Surg 2000;180:475-478. [PubMed: 11182401]
252. Miccoli P, Bendinelli C, Vignali E, Mazzeo S, Cecchini GM, Pinchera A, Marcocci C. Endoscopic parathyroidectomy: report of an initial experience. Surgery
1998;124:1077-1080. [PubMed: 9854586]
253. Starr FL, DeCresce R, Prinz RA. Use of intraoperative parathyroid hormone measurement does not improve success of bilateral neck exploration for
hyperparathyroidism. Arch Surg 2001;136:536-542. [PubMed: 11343544]
254. Zaraca F, Mazzaferro S, Catarci M, Saputelli A, Alò P, Carboni M. Prospective evaluation of total parathyroidectomy and autotransplantation for the
treatment of secondary hyperparathyroidism. Arch Surg 1999;134:68-72. [PubMed: 9927134]
255. Mollerup CL, Lindewald H. Renal stones and primary hyperparathyroidism: natural history of renal stone disease after successful parathyroidectomy.
World J Surg 1999;23:173-176. [PubMed: 9880427]
256. Caccitolo JA, Farley DR, van Heerden JA, Grant CS, Thompson GB, Sterioff S. The current role of parathyroid cryopreservation and autotransplantation in
parathyroid surgery: an institutional experience. Surgery 122:1062-1067, 1997. [PubMed: 9426420]
257. D'Avanzo A, Parangi S, Morita E, Duh QY, Siperstein AE, Clark OH. Hyperparathyroidism after thyroid surgery and autotransplantation of histologically
normal parathyroid glands. J Am Coll Surg 2000;190:546-552. [PubMed: 10801021]
258. Stojadinovic A, Shriver CD, Casler JD, Gaertner EM, York G, Jaques DP. Endoscopic laser excision of ectopic pyriform sinus parathyroid adenoma. Arch
Surg 133:101-103, 1998. [PubMed: 9438768]
259. Burgess JR, David R, Parameswaran V, Greenaway TM, Shepherd JJ. The outcome of subtotal parathyroidectomy for the treatment of
hyperparathyroidism in multiple endocrine neoplasia type 1. Arch Surg 133:126-129, 1998. [PubMed: 9484721]
260. Kikumori T, Imai T, Tanaka Y, Oiwa M, Mase T, Funahashi H. Parathyroid autotransplantation with total thyroidectomy for thyroid carcinoma: Long-term
follow-up of grafted parathyroid function. Surgery 1999;125:504-508. [PubMed: 10330938]
261. Droulias C, Tzinas S, Harlaftis N, Akin JT Jr, Gray SW, Skandalakis JE. The superior laryngeal nerve. Am Surg 1976;42: 635-638.
262. Skandalakis JE, Gray SW. Anatomical complications of thyroidectomy. Am Surg 42:620, 1976.
263. Hellström J, Ivemark BI. Primary hyperparathyroidism: clinical and structural findings in 138 cases. Acta Chir Scand (Suppl) 294:1, 1962. [PubMed:
11415271]
264. Lo CY, Lam KY. Parathyroid autotransplantation during thyroidectomy. Arch Surg 1999;134:258-260. [PubMed: 10088564]
265. Lo CY, Lam KY. Routine parathyroid autotransplantation during thyroidectomy. Surgery 2001;129:318-323. [PubMed: 11231460]
266. Berger AC, Libutti SK, Bartlett DL, Skarulis MG, Marx SJ, Spiegel AM, Doppman JL, Alexander HR. Heterogeneous gland size in sporadic multiple gland
parathyroid hyperplasia. J Am Coll Surg 1999;188:382-389. [PubMed: 10195722]
267. Bucher U, Reid L. Development of the intrasegmental bronchial tree: the pattern of branching and development of cartilage at various stages in intrauterine life. Thorax 16:207, 1961. [PubMed: 13874265]
268. Bucher U, Reid L. Development of the mucus-secreting elements in human lung. Thorax 16:219, 1961. [PubMed: 13874266]
269. Burch M, Balaji S, Deanfield JE, Sullivan ID. Investigation of vascular compression of the trachea: the complementary roles of barium swallow and
echocardiography. Arch Dis Child 1993;68: 171. [PubMed: 8481037]
270. Dover K, Howdieshell TR, Colborn GL. The dimensions and vascular anatomy of the cricothyroid membrane: relevance to emergent surgical airway
access. Clin Anat 9:291-295, 1996. [PubMed: 8842535]
271. Coln CE, Purdue GF, Hunt JL. Tracheostomy in the young pediatric burn patient. Arch Surg 133:537-539, 1998. [PubMed: 9605917]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
122/125
5/24/2014
Print: Chapter 1. Neck
272. Maipang T, Singha S, Panjapiyakul C, Totemchokchyakarn P. Mediastinal tracheostomy. Am J Surg 171:581-586, 1996. [PubMed: 8678204]
273. Ger R, Evans JT. Tracheostomy: an anatomico-clinical review. Clin Anat 1993;6:337.
274. Silen W, Spieker D. Fatal hemorrhage from the innominate artery after tracheostomy. Ann Surg 1965;162:1005. [PubMed: 5321057]
275. Yang FY, Criado E, Schwartz JA, Keagy BA, Willox BR. Trachea-innominate artery fistula: retrospective comparison of treatment methods. South Med J
1988;81:701-706. [PubMed: 3287639]
276. Takano H, Ihara K, Sato S, Yuki K, Kodamo Y, Nakata M. Tracheo-innominate artery fistula following tracheostomy: successful surgical management of a
case. J Cardiovasc Surg 1989;30:860. [PubMed: 2681221]
277. Weiman DS, Pate JW, Walker WA, Brosnan KM, Fabian TC. Combined gunshot injuries of the trachea and esophagus. World J Surg 20:1096-1100, 1996.
[PubMed: 8798371]
278. Upadhyay A, Maurer J, Turner J, Tiszenkel H, Rosengart T. Elective bedside tracheostomy in the intensive care unit. J Am Coll Surg 182:51-55, 1996.
279. Kirchner JA. Tracheostomy and its problems. Surg Clin North Am 1980;60:1093. [PubMed: 7434153]
280. Artz CP, Hardy JD. Management of Surgical Complications (3rd ed). Philadelphia: Saunders, 1960.
281. Bonanno PC. Swallowing dysfunction after tracheostomy. Ann Surg 1971;174:29. [PubMed: 5092509]
282. Roe BB. Bedside tracheostomy. Surg Gynecol Obstet 1962;115: 239. [PubMed: 14493231]
283. Bouquot JE, Gnepp DR, Dardick I, Hietanen JH. Intraosseous salivary tissue: jawbone examples of choristomas, hamartomas, embryonic rests, and
inflammatory entrapment: another histogenic source for intraosseous adenocarcinoma. Oral Surg Oral Med Oral Path Oral Radiol Endodont 2000;90:205-217.
[PubMed: 10936840]
284. Ha SL, Shin JE, Yoon TH. Salivary gland choristoma of the middle ear: a case report. Am J Otolaryngol 2000;21:127-130. [PubMed: 10759000]
285. Martinez Subias J, Royo Lopez J, Valles Varada H. [Congenital absence of major salivary glands]. Acta Otolaryngol Espanola 2000;51:276-278.
286. Anson BJ, McVay CB. Surgical Anatomy (5th ed). Philadelphia, Saunders, 1971, p. 206.
287. Tostevin PMJ, Ellis H. The buccal pad of fat: a review. Clin Anat 1995;8:403. [PubMed: 8713160]
288. Davis RA, Anson BJ, Budinger JM, Kurth LE. Surgical anatomy of the facial nerve and parotid gland based upon a study of 350 cervicofacial halves. Surg
Gynecol Obstet 1956;102:385. [PubMed: 13311719]
289. Winsten J, Ward GE. The parotid gland: an anatomic study. Surgery 1956;40:585. [PubMed: 13360627]
290. Poncet JL, Rondet P, Kossowski M, Cudennec YF, Buffe P. Surgery of the parotid gland: indications, review of the anatomy. Ann Radiol (Paris)
1991;34:122. [PubMed: 1897845]
291. Marks NJ. The anatomy of the lymph nodes of the parotid gland. Clin Otolaryngol 1984;9:271-275. [PubMed: 6509793]
292. Last RJ. Anatomy: Regional and Applied, 5th Ed. Baltimore: Williams & Wilkins, 1972, p. 602.
293. Lescher TC, Hollinshead WH, ReMine WH. Surgical management of benign parotid disease. Am J Surg 1967;113:545.
294. Hogg SP, Kratz RC. Surgical exposure of the facial nerve. Arch Otol 1958;67:560. [PubMed: 13520028]
295. Purcelli FM. Exposure of the facial nerve in parotid surgery: a study of the use of the tympanomastoid suture as a landmark. Am Surg 1963;29:657.
[PubMed: 14070781]
296. Williams HK, Connor R, Edmondson H. Chronic sclerosing sialadenitis of the submandibular and parotid glands: a report of a case and review of the
literature. Oral Surg Oral Med Oral Path Oral Radiol Endodont 2000;89:720-723. [PubMed: 10846127]
297. Tunkel DE, Loury MC, Fox CH, Goins MA, Johns ME. Bilateral parotid enlargement in HIV-seropositive patients. Laryngoscope 1989;99:590-595. [PubMed:
2725154]
298. James DG, Sharma OP. Parotid gland sarcoidosis. Sarcoidosis Vasculitis Diffuse Lung Dis 2000;17:27-32. [PubMed: 10746259]
299. Kelley DJ, Spiro RH. Management of the neck in parotid carcinoma. Am J Surg 172:695-697, 1996. [PubMed: 8988681]
300. Renehan A, Gleaves EN, McGurk M. An analysis of the treatment of 114 patients with recurrent pleomorphic adenomas of the parotid gland. Am J Surg
172:710-714, 1996. [PubMed: 8988685]
301. Forty MJ, Wake MJ. Pleomorphic salivary adenoma in an adolescent. Br Dent J 2000;10:545-546.
302. McKenna RJ. Tumors of the major and minor salivary glands. CA 1984;34:24. [PubMed: 6420017]
303. North CA, Lee DJ, Piantadosi S, Zahurak M, Johns ME. Carcinoma of the major salivary glands treated by surgery or surgery plus postoperative
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
123/125
5/24/2014
Print: Chapter 1. Neck
303. North CA, Lee DJ, Piantadosi S, Zahurak M, Johns ME. Carcinoma of the major salivary glands treated by surgery or surgery plus postoperative
radiotherapy. Int J Radiat Oncol Biol Phys 1990;18:1319-1326. [PubMed: 2115032]
304. Shikhani AH, Johns ME. Tumors of the major salivary glands in children. Head Neck Surg 1988;10:257-263. [PubMed: 3069812]
305. Johns ME. Parotid cancer: a rational basis for treatment. Head Neck Surg 1980;3:132-144. [PubMed: 7440180]
306. Johns ME, Shikhani AH, Kashima HK, Matanoski GM. Multiple primary neoplasms in patients with salivary gland or thyroid gland tumors. Laryngoscope
1986;96:718-721. [PubMed: 3724320]
307. Shikhani AH, Matanoski GM, Jones MM, Kashima HK, Johns ME. Multiple primary malignancies in head and neck cancer. Arch Otolaryngol 1986;112:11721179. [PubMed: 3755993]
308. Johns ME, Rice DH. Malignant neoplasms of the salivary glands. In: English GM (ed). Otolaryngology. Philadelphia: Harper & Row, 1987, vol 5, p. 1-28.
309. Brenner E, Schoeller T. Masseteric nerve: a possible donor for facial nerve anastomosis? Clin Anat 1998;11:396-400. [PubMed: 9800919]
310. Spira M. Anastomosis of masseteric nerve to lower division of facial nerve for correction of lower facial paralysis. Preliminary report. Plast Reconstr Surg
1978;61:330-334. [PubMed: 625495]
311. Fournier HD, Denis F, Papon X, Hentati N, Mercier P. An anatomical study of the motor distribution of the mandibular nerve for a masseteric-facial
anastomosis to restore facial function. Surg Radiol Anat 19:241-244, 1997. [PubMed: 9381330]
312. Sperber GH. Craniofacial Embryology (4th ed). London: Butterworth, 1989.
313. Ziarah MA, Atkinson ME. The surgical anatomy of the mandibular distribution of the facial nerve. Br J Oral Surg 1981; 19:159. [PubMed: 6945120]
314. Martin H. Surgery of Head and Neck Tumors. New York: Hoeber-Harper, 1957.
315. O'Rahilly R. Gardner-Gray-O'Rahilly Anatomy (5th ed). Philadelphia: WB Saunders, 1986, p. 682.
316. Johns ME, Batsakis JG, Short CD. Oncocytic and oncocytoid tumors of the salivary glands. Laryngoscope 1973;83:1940-1952. [PubMed: 4772101]
317. Paulino AF, Huvos AG. Oncocytic and oncocytoid tumors of the salivary gland. Sem Diagn Pathol 1999;16:98-104. [PubMed: 10452575]
318. Wilson CP. Lateral cysts and fistulas of the neck of developmental origin. Ann R Coll Surg Engl 1955;17:1. [PubMed: 13239046]
319. Kim KH, Sung MW, Koh TY, Oh SH, Kim IS. Pyriform sinus fistula: management with chemocauterization of the internal opening. Ann Otol Rhinol Laryngol
2000;109:452-456. [PubMed: 10823473]
320. Brazilian Head and Neck Cancer Study Group. Results of a prospective trial on elective modified radical classical versus supraomohyoid neck dissection in
the management of oral squamous carcinoma. Am J Surg 1998;176:422-27.
321. Kerth JD, Sisson GA, Becker GD. Radical neck dissection in carcinoma of the head and neck. Surg Clin North Am 1973;53: 179. [PubMed: 4702996]
322. Kierner AC, Aigner M, Zelenka I, Riedl G, Burian M. The blood supply of the sternocleidomastoid muscle and its clinical implications. Arch Surg
1999;134:144-147. [PubMed: 10025452]
323. Carney AL, Anderson EM. Hypoglossal carotid entrapment syndrome. Adv Neurol 1981;30:223. [PubMed: 7304301]
324. Gordon SL, Graham WP III Black JT, Miller SH. Accessory nerve function after surgical procedures in the posterior triangle. Arch Surg 1977;112:264.
[PubMed: 843216]
325. Eisen A, Bertrand G. Isolated accessory nerve palsy of spontaneous origin. Arch Neurol 1972;27:496. [PubMed: 5083867]
326. Bell DS. Pressure palsy of the accessory nerve. Br Med J 1964;1: 1483.
327. Singh S, Schlagenhauff RE. Pressure palsy of accessory nerve. Neurol India 1971;18:122.
328. O'Brien CJ. Modified radical neck dissection: terminology, technique and indications. Am J Surg 1987;153:310. [PubMed: 16453390]
329. Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.
330. Saunders JR Jr, Hirata RM, Jaques DA. Considering the spinal accessory nerve in head and neck surgery. Am J Surg 1985;150: 491. [PubMed: 4051114]
331. Soo KC, Strong EW, Spiro RH, Shah JP, Nori S, Green RF. Innervation of the trapezium muscle by the intra-operative measurement of motor action
potentials. Head Neck 1993;15:216. [PubMed: 8491585]
332. Brown H, Burns S, Kaiser CW. The spinal accessory nerve plexus, the trapezium muscle, and shoulder stabilization after radical neck cancer surgery. Ann
Surg 1988;208:654. [PubMed: 3056289]
333. Zibordi F, Baiocco F, Bascelli C, Bini A, Canepa A. Spinal accessory nerve function following neck dissection. Ann Otol Rhinol Laryngol 1988;97:83.
[PubMed: 3341706]
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm
124/125
5/24/2014
Print: Chapter 1. Neck
334. King RJ, Motta G. Iatrogenic spinal accessory nerve palsy. Ann R Coll Surg Engl 1983;65:35. [PubMed: 6824298]
335. Donner TR, Kline DG. Extracranial spinal accessory nerve injury. Neurosurgery 1993;32:907. [PubMed: 8392146]
336. Decker GAG, Du Plessis DJ (eds). Lee McGregor's Synopsis of Surgical Anatomy (12th ed). Bristol, England: John Wright, 1986.
337. Southwick HW, Slaughter DP. Neck dissection: complications and safeguards. Surg Clin North Am 35:31-39, 1955.
338. Batson OV. The adult thyroglossal duct. Anat Rec 1946;94:449.
339. Zarem HA. The management of complications in head and neck surgery. Surg Clin North Am 1973;53:191. [PubMed: 4702997]
340. Nussenbaum B, Liu JH, Sinard RJ. Systemic management of chyle fistula: the Southwestern experience and review of the literature. Otolaryngol Head
Neck Surg 2000;122:31-38. [PubMed: 10629479]
341. Gregor RT. Management of chyle fistulization in association with neck dissection. Otolaryngol Head Neck Surg 2000;122:434-439. [PubMed: 10699823]
342. Moore OS, Karlan M, Sigler L. Factors influencing the safety of carotid ligation. Am J Surg 118:666-668, 1969. [PubMed: 5347083]
343. Schmiedek P, Piepgras A, Leinsinger G, Kirsch CM, Einhupl K. Improvement of cerebrovascular reserve capacity by EC-IC arterial bypass surgery in
patients with ICA occlusion and hemodynamic cerebral ischemia. J Neurosurg 81(2):236-244, 1994.
344. Puttini M, Palmieri B, Romani F, Barbano PR, Riolo F, Rimoldi PA. [Carotid stenosis with contralateral occlusion. Surgical indications and results]. (Italian).
Minerva Cardioangiolog 43(3): 81-84, 1995.
345. Richter HP. (Comments) In: Donner TR, Kline DG. Extracranial spinal accessory nerve injury. Neurosurgery 1993;32:907.
346. Gabel G, Nunley JA. Spinal accessory nerve. In: Gelberman RH (ed). Operative Nerve Repair and Reconstruction. Philadelphia: JB Lippincott, 1991, pp.
445-452.
347. Tindall SC. (Comments) In: Donner TR, Kline DG. Extracranial spinal accessory nerve injury. Neurosurgery 1993;32:907.
348. Saffold SH, Wax MK, Nguyen A, Caro JE, Andersen PE, Everts EC, Cohen JI. Sensory changes associated with selective neck dissection. Otolaryngol
Head Neck Surg 2000;126:425-428. [PubMed: 10722022]
349. Brown H, Hidden G, Ledroux M, Poitevan L. Anatomy and blood supply of the lower four cranial and cervical nerves: relevance to surgical neck
dissection. PSEBM 2000;223:352-361. [PubMed: 10721004]
350. Ducic Y, Hilger PA. The use of unilateral deep plane neck lifting to improve the aesthetic appearance of the neck dissection deformity. Am J Otolaryngol
2000;21:202-206.
351. Clark OH, Way LW, Hunt TK. Recurrent hyperparathyroidism. Ann Surg 1976;184:391-399. [PubMed: 1015886]
352. Edis AJ, Beahrs OH, Sheedy PF. Reoperation for hyperparathyroidism. World J Surg 1977;1:731-738. [PubMed: 607591]
353. Martin JK Jr, van Heerden JA, Edis AJ, Dahlin DC. Persistent postoperative hyperparathyroidism. Surg Gynecol Obstet 1980; 151:764-768.
354. Granberg P, Johansson G, Lindvall N, Ohman U, Wajngot A, Werner S. Reoperation for primary hyperparathyroidism. Am J Surg 1982;143:296-300.
[PubMed: 7065348]
355. Satava RM, Beahrs OH, Scholz DA. Success rate of cervical exploration for hyperparathyroidism. Arch Surg 1975;110:625-628. [PubMed: 1131006]
356. Grant CS, van Heerden JA, Charboneau JW, James EM, Reading CC. Clinical management of persistent and/or recurrent primary hyperparathyroidism.
World J Surg 1986;10:555-565. [PubMed: 3529648]
357. Cheung PS, Borgstrom A, Thompson NW. Strategy in reoperative surgery for hyperparathyroidism. Arch Surg 1989;124:676-680. [PubMed: 2730318]
358. Sugg SL, Fraker DL, Alexander HR. Prospective evaluation of selective venous sampling for parathyroid hormone concentration in patients undergoing
reoperation for primary hyperparathyroidism. Surgery 1993;114:1004-1010. [PubMed: 8256203]
359. Rouviere H. Anatomy of the Human Lymphatic System. Tobias MJ (trans). Ann Arbor MI: Edwards Brothers, 1938.
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